'People pull the rug from under your feet': barriers to successful public health programmes

<p><b>Background:</b> A community public health programme, 'Breathing Space', aimed to tackle smoking in a low income area in Scotland. This paper draws on the qualitative process evaluation of a community-based initiative 'Breathing Space', which set out to tackle smoking in a low income area of Scotland, in order to explore user perceptions of key factors affecting implementation, and in particular to explore the implications of participant knowledge and expertise for programme stability and continuity.</p> <p><b>Methods:</b> The overall evaluation of Breathing Space used a quasi-experimental design and incorporated a detailed process evaluation. The process evaluation aimed to document development and implementation of the programme using a range of qualitative methods, including observation, in-depth interviews, focus groups and documentary analysis. The paper draws upon 59 semi-structured in-depth interviews which were carried out as part of the process evaluation.</p> <p><b>Findings:</b> Staff numbers from the multi-agency partnership dwindled across the lifecouof the programme and respondents identified lack of continuity as a key issue. While staff changes are an anticipated problem in programme implementation, here we draw on concepts of technicality and indeterminacy to explore the different aspects of public health programmes which are forfeited when individuals leave. The paper argues that, while technical components of public health programmes (such as the importance of staff complement and continuity) are widely recognised, it is the more indeterminate aspects, including the loss of key theoretical understanding underpinning the programme, which most affect programme delivery. Indeed, the paper suggests that, where inadequate planning and resources threaten the continuity of indeterminate knowledge, the success of public health programmes may be especially jeopardised.</p> <p><b>Conclusion:</b> Community-based programmes which rely strongly on partnership processes would benefit from early consideration of the potential risks associated with both expected and unexpected stakeholder change. Building in appropriate contingency plans is necessary for sustaining the theory and culture of the programme. Evaluations of innovative community development initiatives may benefit from a formative approach.</p&gt

The Octagon Values Model: community resilience and coastal regeneration

This paper considers efforts to build community resilience through bottom-up responses to socioeconomic and environmental change in coastal communities on the island of Ireland. The discussion adds to a growing body of research which suggests that regeneration initiatives which do not consider a community’s resilience to change will fail to catalyse the changes needed to put that place on a more sustainable trajectory. The Octagon Values Model is presented as a heuristic device for exploring this potentially complimentary and co-influencing relationship between regeneration and resilience building. When applied to two case studies of coastal Transition Towns, the Model illustrates how, in practical terms, resilience may be used to tap into personal concerns to mobilise civil engagement in specific local regeneration initiatives. The discussion highlights some of the perennial practical obstacles confronting voluntary-based, community-level activities which raise questions for the generation of proactive community resilience responses and modes of governance. In capturing environmental, economic, social and governance value domains, the Octagon Values Model illustrates that reconciling values and resource use is critical to both regeneration and resilience ambitions

Creating smoke-free environments: public and private places

The purpose of the critical review is understood to be a critical reflection and comment on the work presented in the papers. The critical review is centred on the papers, as they form the substance of the submission, and the wider tobacco control literature. This review has not attempted to re-analyse the findings of the studies but attempts to draw wider lessons from the studies and to contribute to the future implementation of tobacco control policy and programmes. It will be claimed that the contribution to the research studies, the publications and the critical review represents a significant body of work and contribution to the advancement of knowledge in tobacco control. The aim of the thesis is to present and critically review six publications on the social de-normalisation of tobacco use, as it relates to public and private smoke-free environments and professional engagement in Scotland. The publications are treated as a coherent body of tobacco control research and draw upon three studies conducted over the period 1999-2007. Breathing Space Study 1: 1999-2002 evaluated an intervention which aimed to produce a significant shift in community norms towards non-smoking in a lowincome area. A process evaluation, as part of a quasi-experimental design, was undertaken in the intervention area, using a range of qualitative methods, including observation, in-depth interviews and focus groups. Papers 1 and 2 explore the context of health promotion professional practice in the development and implementation of tobacco control interventions in one disadvantaged community. The Qualitative Community Study 2: 2005-2007 aimed to explore the impact of the Scottish smoke-free legislation on attitudes and behaviour, at both individual and community levels, in four socio-economically contrasting localities in Scotland. A longitudinal qualitative evaluation was conducted using observation, in-depth interviews with smokers and ex-smokers, key stakeholders and focus groups. Papers 3 and 4 explore qualitative differences in the experience of smoke-free legislation in advantaged and disadvantaged communities, with particular consideration of the unintended consequences of the legislation for some smokers. The Smoke-free Homes Study 3: 2006-2007 aimed to describe changes in smoking behaviour and attitudes to smoking following implementation of the smoke-free legislation. It sought to identify the potential enablers and barriers to reducing SHS exposure in the home. A cross-sectional study was conducted using qualitative interviews. Papers 5 and 6 explore the changing discourses about second-hand smoke exposure, and the development of smoking restrictions in the home, with a particular focus on motivation to protect children. In addition, insight into the changing culture of professional practice in creating smoke-free homes was gained. Key findings A synthesis of key findings from these publications supports the identification of three major themes: the experience of power at each stage of the process of the social de-normalisation of tobacco use; the experience of stigmatisation of smoking as a consequence of policy; and health promotion practice as both barrier to and enabler of the implementation of smoke-free environments in the community and the home. The thesis also highlights the benefits and challenges of two research methodologies, process evaluation and qualitative longitudinal research (QLLR), in capturing both intended and unanticipated aspects of policy and practice implementation. This synthesis of the key findings that cut across the three studies has generated four research questions that are explored in this critical review: 1. How can policy be evaluated in community settings and in the home? 2. How do smokers, particularly disadvantaged smokers, engage with tobacco control policies and interventions? 3. Is professional practice a barrier or facilitator to understanding the impact of tobacco control policies and interventions? 4. What are some of the key unintended consequences of recent tobacco control policies? Conclusion This thesis contributes to knowledge through a critical account of the reshaping of smoking as a collective lifestyle, in both public and private domains. The social de-normalisation of tobacco use is experienced differently in advantaged and disadvantaged social contexts. Population tobacco control strategies may benefit from contextual adjustments, particularly for those smokers who live in areas of disadvantage and thus experience dual stigmatisation. Additionally, the effectiveness of future interventions would be enhanced by a more nuanced understanding of smoking behaviour, as a collective social practice, embedded in specific spaces, places and times

My Diabetes My Way:supporting online diabetes self-management: progress and analysis from 2016

Abstract Background My Diabetes My Way (MDMW) is the National Health Service (NHS) Scotland website for people with diabetes and their carers. It consists of an interactive information website and an electronic personal health record (ePHR) available to the 291,981 people with diabetes in Scotland. We aimed to analyse the demographic characteristics of current registrants and system usage and activity during 2016. Methods We analysed system audit trails to monitor user activity and page accesses on the information website, and logins and activity within the ePHR. The ePHR contains data from SCI-Diabetes, NHS Scotland’s flagship diabetes record, sourcing data from primary and secondary care, specialist screening services and laboratory systems. We reviewed patient registration characteristics to collate demographic data for the MWDH cohort, then compared this to aggregate data published in the 2016 Scottish Diabetes Survey. The Scottish Diabetes Survey is an annual population-based report detailing diabetes statistics for the whole diabetes population in NHS Scotland. Results The MDMW information website received an average of 101,382 page accesses per month during 2016 (56.9% increase from 2015; n = 64,607). ePHR registrants were more likely to be younger (p < 0.001) and have an ethnicity of “white” (p < 0.001) than the background diabetes population. At the end of 2016, 11,840 people with diabetes had accessed their personal clinical information (58.6% increase since end 2015; n = 7464). During 2016, an average of 1907 people accessed their records each month (48.3% increase from 2015; n = 1286). Conclusion My Diabetes My Way is a useful tool aid to diabetes self-management. The service is unique in offering records access to a national population, providing information from all relevant diabetes-related sources, rather than a single silo. MDMW supports the diabetes improvement, self-management, healthcare quality and eHealth strategies of the Scottish Government. The service also has potential to be adapted to work with other clinical systems and conditions

An interview study of pregnant women who were provided with indoor air quality measurements of second hand smoke to help them quit smoking

Background:&nbsp; Maternal smoking can cause health complications in pregnancy. Particulate matter (PM2.5) metrics applied to second hand smoke (SHS) concentrations provide indoor air quality (IAQ) measurements and have been used to promote smoking behaviour change among parents of young children. Here, we present the qualitative results from a study designed to use IAQ measurements to help pregnant women who smoke to quit smoking.&nbsp; Methods:&nbsp; We used IAQ measurements in two centres (Aberdeen and Coventry) using two interventions: 1. In Aberdeen, women made IAQ measurements in their homes following routine ultrasound scan; 2. In Coventry, IAQ measurements were added to a home-based Stop Smoking in Pregnancy Service. All women were invited to give a qualitative interview to explore acceptability and feasibility of IAQ measurements to help with smoking cessation. A case study approach using grounded theory was applied to develop a typology of pregnant women who smoke.&nbsp; Results:&nbsp; There were 39 women recruited (18 in Aberdeen and 21 in Coventry) and qualitative interviews were undertaken with nine of those women. Diverse accounts of smoking behaviours and experiences of participation were given. Many women reported changes to their smoking behaviours during pregnancy. Most women wanted to make further changes to their own behaviour, but could not commit or felt constrained by living with a partner or family members who smoked. Others could not envisage quitting. Using themes emerging from the interviews, we constructed a typology where women were classified as follows: 'champions for change'; 'keen, but not committed'; and 'can't quit, won't quit'. Three women reported quitting smoking alongside participation in our study.&nbsp; Conclusions:&nbsp; Pregnant women who smoke remain hard to engage,. Although providing IAQ measurements does not obviously improve quit rates, it can support changes in smoking behaviour in/around the home for some individuals. Our typology might offer a useful assessment tool for midwives

Human subjects protection issues in QUERI implementation research: QUERI Series

<p>Abstract</p> <p>Background</p> <p>Human Subjects protections approaches, specifically those relating to research review board oversight, vary throughout the world. While all are designed to protect participants involved in research, the structure and specifics of these institutional review boards (IRBs) can and do differ. This variation affects all types of research, particularly implementation research.</p> <p>Methods</p> <p>In 2001, we began a series of inter-related studies on implementing evidence-based collaborative care for depression in Veterans Health Administration primary care. We have submitted more than 100 IRB applications, amendments, and renewals, and in doing so, we have interacted with 13 VA and University IRBs across the United States (U.S.). We present four overarching IRB-related themes encountered throughout the implementation of our projects, and within each theme, identify key challenges and suggest approaches that have proved useful. Where applicable, we showcase process aids developed to assist in resolving a particular IRB challenge.</p> <p>Results</p> <p>There are issues unique to implementation research, as this type of research may not fit within the traditional Human Subjects paradigm used to assess clinical trials. Risks in implementation research are generally related to breaches of confidentiality, rather than health risks associated with traditional clinical trials. The implementation-specific challenges discussed are: external validity considerations, Plan-Do-Study-Act cycles, risk-benefit issues, the multiple roles of researchers and subjects, and system-level unit of analysis.</p> <p>Discussion</p> <p>Specific aspects of implementation research interact with variations in knowledge, procedures, and regulatory interpretations across IRBs to affect the implementation and study of best methods to increase evidence-based practice. Through lack of unambiguous guidelines and local liability concerns, IRBs are often at risk of applying both variable and inappropriate or unnecessary standards to implementation research that are not consistent with the spirit of the Belmont Report (a summary of basic ethical principles identified by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research), and which impede the conduct of evidence-based quality improvement research. While there are promising developments in the IRB community, it is incumbent upon implementation researchers to interact with IRBs in a manner that assists appropriate risk-benefit determinations and helps prevent the process from having a negative impact on efforts to reduce the lag in implementing best practices.</p