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A framework for understanding relationships between school connectedness and student aberrant behaviors is outlined that is synthesized from Merton's insights into anomie and Bernstein's theory of cultural transmission (which focuses on schools' instructional methods and students' internalization of schools' values). A seven-category classification system identifies students' risk of nonconformist behavior based upon students acceptance/rejection of dominant overarching cultural aspirations (commonly material prosperity); perception of schools' role in aspiration realization; responses to schools' instructional methods; and internalization of schools' values regarding conduct/character. We propose frustration weakens connectedness and is grounded in students' perceptions regarding their school's educational outcomes, degree of acceptance at school, and their school's values. We then consider student dispersal across schools, and how age may affect students' categorization and the influence of frustration risk factors. Finally, we discuss how initiatives within school organization, curriculum, and pedagogic practice may promote connectedness among different student categories and their potential adverse consequences.

Purpose: The purpose of this paper is to extend a theory of health promoting schools (Markham and Aveyard, 2003) that draws heavily upon Nussbaum's Aristotelian interpretation of good human functioning (Nussbaum, 1990). This theory of health promoting schools proposed that health is grounded in the meeting of identified fundamental human needs and the realisation of identified essential human capacities (Markham and Aveyard, 2003). Design/methodology/approach: The extension of this theory is achieved through the application of influential social theories with practical tenets to Nussbaum's insights (Nussbaum, 1990). This extension includes additional essential human capacities, a description and definition of how good human functioning may be recognised, potential limitations of the capabilities approaches and a discussion of major factors inhibiting good human functioning. Findings: The potential contribution of the outlined framework to discussions of health and health promotion is highlighted in two ways. First, this paper considers how the outlined framework may contribute to discussions of quality of life, morbidity/premature mortality and health-related behaviours. Second, this paper briefly considers how the outlined framework may contribute to discussions of public health policy, and the planning, delivery and evaluation of health promotion initiatives. Basic exemplar pre- and post-questionnaires for a hypothetical health promoting community development programme are offered. Originality/value: This paper attempts to contribute to discussions of the application of Nussbaum's Aristotelean interpretation of good human functioning to both public health and health promotion.

Objectives: It has been suggested that students are healthier in schools where more students are committed to school. Previous research has examined this only using a proxy measure of value-added education (a measure of whether school-level attendance and attainment are higher than predicted by students' social profile), finding associations with smoking tobacco, use of alcohol and illicit drugs, and violence. These findings do not provide direct insights into the associations between school-level aggregate student commitment and health behaviours, and may simply reflect the proxy measure being residually confounded by unmeasured student characteristics. We examined the previously used proxy measure of value-added education, as well as direct measures at the level of the school and the student of lack of student commitment to school to see whether these were associated with students' self-reported smoking tobacco, alcohol use and school misbehaviour. Design: Cross-sectional survey. Setting: A total of 40 schools in south-east England. Methods: Multi-level analyses. Results: There were associations between school- and student-level measures of lack of commitment to school and tobacco smoking, alcohol use and school misbehaviour outcomes, but the proxy measure of school-level commitment, value-added education, was not associated with these outcomes. A sensitivity analysis focused only on violent aspects of school misbehaviour found a pattern of associations identical to that found for the measure of misbehaviour. Conclusion: Our study provides the first direct evidence in support of the Theory of Human Functioning and School Organisation.

Purpose: The purpose of this paper is to report the process evaluation of a pilot randomised control trial of an anti-smoking intervention for Malaysian 13-14-year olds, conducted in 2011/2012. It was hypothesised that trained peer supporters would promote non-smoking among classmates through informal conversations. Design/methodology/approach: Smoking-related baseline and follow-up questionnaires were administered, seven months apart, to Form 1 students (n = 2,118) attending eight schools across two districts in Sabah (Kota Kinabalu; Keningau). Concealed stratified randomisation assigned two schools per district to the control and intervention arms. Control schools received usual care. Intervention schools received usual care and the peer supporter intervention. Peer supporters completed smoking-related knowledge and attitudes questionnaires before and after peer supporter training and peer supporter training evaluation questionnaires. They also discussed the peer supporter training and role in focus groups immediately following training (n = 4) and three months later (n = 3), and additionally, recorded post-training anti-smoking activity in diaries. Findings: The pilot trial found that student recruitment was high (baseline students matched at follow-up n = 1,681 (79 per cent of class-registered students). More boys (n = 38) than girls (n = 35) attended peer supporter training. Post-training, most peer supporters had improved smoking-related knowledge (n = 55; 75 per cent) and attitudes (n = 57; 78 per cent) and returned diaries (n = 49; 67 per cent). Some focus group boys reported they were reluctant peer supporters and/or found resisting smoking difficult. Practical implications: Future trials would benefit from outlined modifications to peer supporter selection, recruitment and training and additionally, assessments of context and intervention acceptability and reach. Originality/value: Trials of complex public health interventions are scarce in economically developing countries.

This paper outlines a conceptual and operational framework for understanding the relationships between school culture and teenage substance use (smoking, drinking and illicit drug use). The framework draws upon Bernstein's theory of cultural transmission, a theory of health promoting schools and a frame for understanding the effects of place on health. It is proposed that the strength/weakness of classification (boundaries within school and between the school and outside world) and framing (communication) determine each school's (1) organisation, curriculum and pedagogic practice and (2) valued school identities and school-oriented learning opportunities for cognitive and affective development. These identities and learning opportunities are based either on performance or personal development and social relations. Likely teacher/student identity pairings in schools promoting performance and schools promoting personal development and social relations are discussed. Schools promoting performance-based identities and opportunities may potentially have higher school-level substance use. Students adopting a valued school identity are at lowest risk of substance use. Students who are unwilling/unable to adopt a valued school identity and disengage with school-oriented learning opportunities for cognitive and affective development are at highest risk of substance use. The potential pathways through which identified contextual (structural), collective (sociocultural) and compositional (individual-level) factors may modify these relationships through school-level and individual-level meaningfulness are described. Finally, school culture-based interventions that draw on the framework outlined in this paper that may positively affect student substance use across schools are discussed.

Background: Routine childhood vaccination coverage rates fell in many countries during the COVID-19 pandemic, but the impact of inequity on coverage is unknown. Methods: We synthesised evidence on inequities in routine childhood vaccination coverage (PROSPERO, CRD 42021257431). Studies reporting empirical data on routine vaccination coverage in children 0–18 years old during the COVID-19 pandemic by equity stratifiers were systematically reviewed. Nine electronic databases were searched between 1 January 2020 and 18 January 2022. The risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Tool for Cohort Studies. Overall, 91 of 1453 studies were selected for full paper review, and thirteen met the inclusion criteria. Results: The narrative synthesis found moderate evidence for inequity in reducing the vaccination coverage of children during COVID-19 lockdowns and moderately strong evidence for an increase in inequity compared with pre-pandemic months (before March 2020). Two studies reported higher rates of inequity among children aged less than one year, and one showed higher inequity rates in middle- compared with high-income countries. Conclusions: Evidence from a limited number of studies shows the effect of the pandemic on vaccine coverage inequity. Research from more countries is required to assess the global effect on inequity in coverage. [ABSTRACT FROM AUTHOR]

The objectives of this review were to examine whether smoking prevalence varies between schools independently of health promotion programmes and pupil composition, to show which school characteristics are responsible for this variation, and to examine the methodological adequacy of such studies. Searches for published studies were performed on medical, educational and social science databases, relevant articles' reference lists, and citation searches. Any study was included that described inter-school variation in smoking prevalence, or related such variation to school characteristics. A model relating pupil smoking to school, neighbourhood, and pupil characteristics unlikely and likely to be influenced by school was used to examine the adequacy of control of confounding by pupil composition. Data from studies were combined qualitatively considering methodological adequacy to examine the relation of smoking prevalence to school characteristics. Theoretical frameworks underpinning the choice of school characteristics and postulated relationships between these characteristics and smoking prevalence were described. There were large variations in smoking prevalence between ostensibly similar schools. Evidence that pupil composition did not cause this was weak, because all studies had methodological problems, including under control of relevant pupil compositional factors and over control of factors likely to represent the mechanism through which schools influence pupils' smoking. There was little evidence that elements of tobacco control policy other than bans and enforcement deterred smoking. Academic practice and school ethos were related to smoking. Academically selective schools did not influence smoking, once pupil composition was controlled. There was one study on neighbourhood influences, which were unrelated to smoking. Studies frequently offered little or no theoretical justification for associating school characteristics with smoking. Some aspects of school influence pupils' smoking, probably independently of pupil composition. However, under-control and over-control of confounding and lack of theoretical underpinning precludes definitive conclusions on how particular school characteristics influence pupils' smoking. Keywords: Schools; Pupil composition: Contextual factors: Multilevel modelling; Smoking

School factors and not solely pupil composition probably cause variation in smoking prevalence amongst schools, but there are no theoretical models to explain why. In this paper we propose a hypothesis to explain schools' influence on pupils' smoking and test this using an existing cross-sectional survey of 23,282 pupils from 166 secondary schools in the West Midlands, UK. We hypothesise that school-level educational achievement scores would not be associated with smoking prevalence, but schools providing value-added education given the social background of pupils (authoritative schools) would provide effective support and control, have a relatively strong influence on pupils' lives and be associated with lower than average smoking prevalence. Schools providing value-denuded education (laissez-faire schools) would have a relatively weak influence on pupils' lives and be associated with higher than average smoking prevalence. The school achievement measures were the proportion of pupils achieving 5A C General Certificates of Secondary Education (5A-Cs) grades and the proportion of half days lost to truancy. Value-added/denuded terms were created by regressing 5A-Cs and truancy on five markers of the social profile of pupils at the school. Authoritative schools achieved better than expected rates on both measures. Laissez-faire schools achieved worse than expected rates on both measures. All other schools were classed as indeterminate. Multilevel logistic regression was used to relate the risk of regular smoking to school culture in both achievement and authoritative/laissez-faire terms, both with and without adjustment for pupil-level risk factors for smoking. As predicted, schools' achievement measures were unrelated to pupils' smoking. The odds ratios (95% confidence intervals) for smoking in authoritative and laissez-faire schools relative to indeterminate schools were 0.80 (0.70 0.91) and 1.16 (1.07 1.27), respectively. Adjustment for pupil-level smoking risk factors had little effect. School culture is an independent risk factor for adolescent smoking. Schools providing effective support and control might protect pupils from smoking. Keywords: Smoking; Schoolchildren: Health-promoting schools; UK

This paper outlines a novel explanatory frame for understanding how schools may intervene in order to promote pupils' health. The new theory is synthesised from an Aristotelian interpretation of human functioning and a theory of cultural transmission. In keeping with recent influential theoretical developments, it is proposed that health has its roots in human functioning. It follows from this concept that the promotion of pupils' health is facilitated by the promotion of pupil functioning and the primary mechanisms through which schools promote pupil functioning and, hence, health, are through the influences of school organisation, curriculum development and pedagogic practice on pupil development. According to the new theory, good human functioning is dependent on the realisation of a number of identified essential human capacities and the meeting of identified fundamental human needs. Two essential capacities, the capacity for practical reasoning and the capacity for affiliation with other humans, plan and organise the other essential capacities. The realisation of these two capacities should, it is argued; be the primary focus of health promoting schools. Additionally, health promoting schools should ensure that fundamental human needs concerning non-useful pain and information about the body are met. A number of testable hypotheses are generated from the new theory. Comparisons with existing interpretations of health promoting schools indicate there are similarities in the actions schools should take to promote health. However, the new theory can, uniquely, be used to predict which pupils will enjoy the best health at school and in adulthood. Additionally, according to the new theory, schools do not need designated health education classes or teaching staff with specialist health education roles in order to be health promoting. It is concluded that the new theory may have a number of advantages over existing theories at both the policy and intervention levels. Keywords: School; Health promotion; Human functioning

Health promotion interventions cannot work if people do not engage with them. The aim of this study was to examine whether disengagement from an adolescent smoking prevention and cessation intervention was an independent risk factor for regular smoking 1 and 2 years later. The data were taken from a cluster randomised controlled trial, in the West Midlands, UK, based on the transtheoretical or stages of change model. In this trial, 8352 13-14-year old school pupils enrolled, and the data in this report were based on the 7413 and 6782 pupils present at 1 and 2 years follow-ups, respectively. The intervention group undertook three sessions using an interactive computer programme. At the end of the programme, pupils recorded their responses to it. Pupils were classed as engaged if they thought the intervention was both useful and interesting; all others were classed as disengaged. Random effects logistic regression related the number of times engaged to regular smoking at 1 and 2 years follow-up, adjusted for school absences and 11 potential confounders. The majority of pupils were engaged by the intervention. For participants using the intervention three times but not engaging once, the odds ratios (95% confidence intervals) for smoking at 1 and 2 years relative to the controls were 1.83 (1.41-2.39) and 1.70 (1.38-2.11). For those engaging three times, they were 0.79 (0.60-1.03) and 0.96 (0.75-1.21). There was no interaction with baseline intention to smoke, classified by stage of change, but there was a borderline significant interaction with baseline smoking status, with disengagement acting as a stronger risk factor among baseline never-smokers. We conclude that disengagement from interventions is a risk factor for smoking independently of experimentation with cigarettes. The best explanation is that disengagement from school, an established risk factor for smoking, generalises to disengagement from didactic school-based health promotion programmes. Keywords: Smoking; Adolescence; Schools; Smoking prevention; Randomised controlled trial; UK

Objective: This study aimed to examine social gradients in ADHD during late childhood (age 9–11 years) using absolute and relative relationships with socioeconomic status exposure (household income, maternal education) during early childhood (<5 years) in seven cohorts from six industrialised countries (UK, Australia, Canada, The Netherlands, USA, Sweden). Methods: Secondary analyses were conducted for each birth cohort. Risk ratios, pooled risk estimates, and absolute inequality, measured by the Slope Index of Inequality (SII), were estimated to quantify social gradients in ADHD during late childhood by household income and maternal education measured during early childhood. Estimates were adjusted for child sex, mother age at birth, mother ethnicity, and multiple births. Findings: All cohorts demonstrated social gradients by household income and maternal education in early childhood, except for maternal education in Quebec. Pooled risk estimates, relating to 44,925 children, yielded expected gradients (income: low 1.83(CI 1.38,2.41), middle 1.42(1.13,1.79), high (reference); maternal education: low 2.13(1.39,3.25), middle 1.42(1.13,1.79)). Estimates of absolute inequality using SII showed that the largest differences in ADHD prevalence between the highest and lowest levels of maternal education were observed in Australia (4% lower) and Sweden (3% lower); for household income, the largest differences were observed in Quebec (6% lower) and Canada (all provinces: 5% lower). Conclusion: Findings indicate that children in families with high household income or maternal education are less likely to have ADHD at age 9–11. Absolute inequality, in combination with relative inequality, provides a more complete account of the socioeconomic status and ADHD relationship in different high-income countries. While the study design precludes causal inference, the linear relation between early childhood social circumstances and later ADHD suggests a potential role for policies that promote high levels of education, especially among women, and adequate levels of household income over children's early years in reducing risk of later ADHD. [ABSTRACT FROM AUTHOR]

Background: ADHD is one of the most prevalent mental health disorders among children and adolescents. Household socio-economic status (SES) in early childhood is inversely related to ADHD later in childhood or adolescence. We conducted a systematic review to examine psychological, social and behavioural factors that mediate these relationships (PROSPERO Registration number: CRD42020182832). Methods and findings: We searched Medline, EMBASE, PsychINFo, and Web of Science from inception until May 2020. Both authors independently reviewed abstracts and identified papers for inclusion. We sought primary observational studies (cohort, cross-sectional and case control studies) of general population-based samples of children and adolescents aged 18 and under that investigated potential mediators of the relationships between SES and ADHD. Studies based upon non-general population-based samples, twins or biochemical/physiological changes were excluded. Direct and indirect effects derived from standard validated mediation analysis were extracted for potential mediators. We assessed risk of bias using a modified NIH tool and synthesised quantitative data without meta-analysis according to the (SWiM) protocol because of heterogeneity between included studies. Family adversity, paternal and maternal ADHD symptoms, Home Learning Environment, breastfeeding duration and a combined fine motor and language score at age 2 may lie on the SES-ADHD pathway. Evidence concerning the influence of maternal depression/anxiety and adverse parenting was inconsistent across studies. There was no evidence that mother's health-related behaviour, family characteristics, child's consumption of fizzy drinks or other developmental characteristics at birth/during infancy lie on the SES-ADHD pathway. Publication bias may have been introduced by our decision not to search grey literature, not to approach study authors and limit the search to the English language. Conclusions: Evidence for mediation of the SES-ADHD pathway in childhood/adolescence is under-researched. Maternal mental health, family adversity, parenting and health-related behaviours warrant further research based on longitudinal data and employing the most advanced mediation analysis methods. [ABSTRACT FROM AUTHOR]

Abstract Background Many young people report they want to stop smoking and have tried to do so, but most of their quit attempts fail. For adult smokers, there is strong evidence that group behavioural support enhances quit rates. However, it is uncertain whether group behavioural support enhances abstinence in young smokers trying to quit. Findings A cluster randomised trial for young people trying to stop smoking to compare the efficacy of a school-based 9 week intensive group behavioural support course versus a school-based 7 week brief advice only course. Participants were assessed for evidence of tobacco addiction and nicotine replacement therapy (NRT) was used if it was deemed appropriate by the therapist. Both types of course aimed to recruit approximately one hundred participants from approximately ten schools. The primary outcome was successful quitting at 4 weeks after quit day judged according to the Russell standard. Had the trial been completed, abstinence at 6 months after quit day and the relationships between successful quit attempts and 1) psychological assessments of dependence prior to quitting 2) salivary cotinine concentration prior to quitting and 3) sociodemographic characteristics would also have been assessed. The proportion of participants who stopped smoking in each arm of the trial were compared using Chi square tests. The trial was stopped shortly after it had started because funding to support the therapists running the stop smoking group behavioural support programme was withdrawn. Only three stop smoking courses were completed (two group support courses and one brief advice pharmacotherapy course). Seventeen participants in total entered the trial. At the end of the courses, one participant (10%) attending the group support programme had stopped smoking and no participant attending the brief advice programme had stopped smoking. Discussion The trial was stopped so we were unable to determine whether group support helped more young people to stop smoking than brief advice. Engagement and recruitment of participants proved much more difficult than had been anticipated. Fifteen of the seventeen participants reported that quitting smoking was either pretty important or very important to them. Thus, the stop smoking success rate could, nevertheless, be considered disappointing. Trial registration Current Controlled Trials ISRCTN25181936

Abstract Background European trans-national adolescent smoking prevention interventions based on social influences approaches have had limited success. The attitudes-social influences-efficacy (ASE) model is a social cognition model that states smoking behaviour is determined by smoking intention which, in turn, is predicted by seven ASE determinants; disadvantages, advantages, social acceptance, social norms, modelling, perceived pressure, self-efficacy. Distal factors such as country of residence, age and gender are external to the model. The ASE model is, thus, closely related to the Theory of Planned Behaviour. This study assessed the utility of the ASE model using cross-sectional data from Spanish and UK adolescents. Methods In 1997, questionnaires were simultaneously administered to Spanish (n = 3716) and UK adolescents (n = 3715) who were considered at high risk of smoking. Participants' age, gender, smoking intentions and ASE determinant scores were identified and linear regression analysis was used to examine the mediated, moderated and direct effects of country of residence, age and gender on participants' smoking intentions. Results All UK participants were aged 12 or 13 and most Spanish participants were aged between 12 and 14 (range 12–16 years). Amongst 12 and 13 year olds, regular smoking was more common in Spain. Almost half the participants were female (47.2% in Spain; 49.9% in the UK). Gender did not vary significantly according to age. The distribution of ASE determinant scores varied by country and predicted intention. The influence of each ASE determinant on intention was moderated by country. Country had a large direct influence on intention (1.72 points on a 7 point scale) but the effects of age and gender were mediated by the ASE determinants. The findings suggest resisting peer pressure interventions could potentially influence smoking amongst UK adolescents but not Spanish adolescents. Interventions that promote self-efficacy, on the other hand, would possibly have a greater influence on smoking amongst Spanish adolescents. Conclusion The ASE model may not capture important cultural factors related to adolescent smoking and the relative contribution of particular ASE determinants to adolescent smoking intentions may differ between countries. Future European trans-national adolescent smoking prevention programmes may benefit from greater undestanding of country-level cultural norms.

The theory of human functioning and school organisation informed by Basil Bernstein’s sociology of education suggests that to gain the commitment and promote the health of students, particularly those from disadvantaged backgrounds, schools require radical transformations eroding various ‘boundaries’: between and among staff and students; between students’ academic learning and broader social development and welfare; and between schools and their local communities. Existing research examining this theory has reported associations between school-level proxy measures of student commitment and lower rates of student smoking, drinking alcohol, use of drugs and violence. But this research has not directly assessed whether reduced school boundaries explain this. We piloted a new scale derived from teacher reports to measure unhealthy school boundaries and examined its inter-item reliability and its criterion validity in terms of associations with various measures of school commitment and smoking. Data on boundaries came from 101 teachers across 40 schools. Data on student commitment and smoking came from 6667 students. We assessed reliability by examining correlations between scale-items and criterion validity in terms of associations with student-reported commitment and smoking. Inter-item reliability was sub-optimal but better within the subscales about boundaries between academic/broader learning and schools/local communities. The scale had good criterion validity, strongly associated with reduced student-reported school commitment and increased student-reported smoking. We reflect on the implications of these findings in terms of critical perspectives on health promotion in schools and the strengths and limitations of quantitative research in examining health behaviours as opposed to practices. [ABSTRACT FROM PUBLISHER]

Background: Many young people report they want to stop smoking and have tried to do so, but most of their quit attempts fail. For adult smokers, there is strong evidence that group behavioural support enhances quit rates. However, it is uncertain whether group behavioural support enhances abstinence in young smokers trying to quit. Findings: A cluster randomised trial for young people trying to stop smoking to compare the efficacy of a school-based 9 week intensive group behavioural support course versus a school-based 7 week brief advice only course. Participants were assessed for evidence of tobacco addiction and nicotine replacement therapy (NRT) was used if it was deemed appropriate by the therapist. Both types of course aimed to recruit approximately one hundred participants from approximately ten schools. The primary outcome was successful quitting at 4 weeks after quit day judged according to the Russell standard. Had the trial been completed, abstinence at 6 months after quit day and the relationships between successful quit attempts and 1) psychological assessments of dependence prior to quitting 2) salivary cotinine concentration prior to quitting and 3) sociodemographic characteristics would also have been assessed. The proportion of participants who stopped smoking in each arm of the trial were compared using Chi square tests. The trial was stopped shortly after it had started because funding to support the therapists running the stop smoking group behavioural support programme was withdrawn. Only three stop smoking courses were completed (two group support courses and one brief advice pharmacotherapy course). Seventeen participants in total entered the trial. At the end of the courses, one participant (10%) attending the group support programme had stopped smoking and no participant attending the brief advice programme had stopped smoking. Discussion: The trial was stopped so we were unable to determine whether group support helped more young people to stop smoking than brief advice. Engagement and recruitment of participants proved much more difficult than had been anticipated. Fifteen of the seventeen participants reported that quitting smoking was either pretty important or very important to them. Thus, the stop smoking success rate could, nevertheless, be considered disappointing. Trial registration: Current Controlled Trials ISRCTN25181936 [ABSTRACT FROM AUTHOR]

There is a growing evidence base on what schools need to do to promote mental health effectively. There is strong evidence that they need first and foremost to use a whole school approach. This shapes the social contexts which promote mental health and which provide a backdrop of measures to prevent mental health disorders. In this context the targeting of those with particular needs and the work of the specialist services can be much more effective. Schools need to use positive models of mental health, which emphasise well being and competence not just illness- this will help overcome problems of stigma and denial and promote the idea of mental health as 'everyone's business'. The most effective programmes in schools which address mental health have the following characteristics:• They provide a backdrop of universal provision to promote the mental health of all and then target those with special needs effectively.• They are multi-dimensional and coherent.• They create supportive climates that promote warmth, empathy, positive expectations and clear boundaries.• They tackle mental health problems early when they first manifest themselves and then take a long term, developmental approach which does not expect immediate answers.• They identify and target vulnerable and at risk groups and help people to acquire the skills and competences that underlie mental health.• They involve end users and their families in ways that encourage a feeling of ownership and participation, and provide effective training for those who run the programmes, including helping them to promote their own mental health.Using these starting points, we need to develop a rigorous evidence-based approach on this issue. We also require the facilitation of the dissemination of such research findings while encouraging new and innovative approaches. [ABSTRACT FROM PUBLISHER]

Objectives: The National Strategy for Sexual Health and HIV aims to facilitate improved patient access to sexual health care, primarily in general practice. This study aimed to identify sexual health care provision in general practitioner (GP) training practices and highlight training and resource implications of the strategy for GPs and prospective GPs.Methods: Data were gathered from interviews with five key representatives (all of whom had a special interest in GP training and/or sexual health care) and a self-completed questionnaire survey of all 374 GP trainers in the West Midlands region. The questionnaire was developed from the interviews and comprised three sections: sample characteristics; current practice; and 30 statements to elicit attitudes, knowledge and training implications. The questionnaire was mailed out in March 2002 with two re-mailings at 2-week intervals.Results: Most GP trainers (79%; n=295) returned completed questionnaires. Most respondents were already offering some 'Level 1 services' or were prepared to including cervical screening (100%; n=295), sexual history taking (95%; n=271), sexually transmitted infection (STI) testing (74%; n=217), HIV testing (68%; n=198) and contraceptive services (71%; n=208). However, most (86%; n=251) needed further information on the Strategy detail and its implications. Training needs in sexual history taking, STI testing and HIV testing were also highlighted. Most GP trainers (62%; n=181) believed GP registrars were relatively unprepared for sexual health care and proposed improved training and assessment. Appropriate nurse training should also be provided.Conclusion: Although 82% (n=242) of respondents would implement the Strategy if properly resourced, considerable training and support needs were identified. [ABSTRACT FROM AUTHOR]