Implementing complete smokefree policies in mental health inpatient settings Results from a before and after mixed-methods evaluation : results from a before and after mixed-methods evaluation

Abstract Background Tobacco smoking is extremely prevalent in people with severe mental illness (SMI) and has been recognised as the main contributor to widening health inequalities in this population. Historically, smoking has been deeply entrenched in the culture of mental health settings in the UK, and until recently, smokefree policies tended to be only partially implemented. However, recent national guidance and the government’s tobacco control plan now call for the implementation of complete smokefree policies. Many mental health Trusts across the UK are currently in the process of implementing the new guidance, but little is known about the impact of and experience with policy implementation. Methods This paper reports findings from a mixed-methods evaluation of policy implementation across 12 wards in a large mental health Trust in England. Quantitative data were collected and compared before and after implementation of NICE guidance PH48 and referred to 1) identification and treatment of tobacco dependence, 2) smoking-related incident reporting, and 3) prescribing of psychotropic medication. A qualitative exploration of the experience of inpatients was also carried out. Descriptive statistical analyses were performed, and the feasibility of collecting relevant and complete data for each quantitative component was assessed. Qualitative data were analysed using thematic framework analysis. Results Following implementation of the complete smokefree policy, increases in the numbers of patients offered smoking cessation advice (72% compared to 38%) were identified. While incident reports demonstrated a decrease in challenging behaviour during the post-PH48 period (6% compared to 23%), incidents relating to the concealment of smoking materials increased (10% compared to 2%). Patients reported encouraging changes in smoking behaviour and motivation to maintain change after discharge. However, implementation issues challenging full policy implementation, including covert facilitation of smoking by staff, were reported, and difficulties in collecting relevant and complete data for comprehensive evaluation purposes identified. Conclusions Overall, the implementation of complete smokefree policies in mental health settings may currently be undermined by partial support. Strategies to enhance support and the establishment of suitable data collection pathways to monitor progress are required

Treating tobacco dependence in older adults: a survey of primary care clinicians’ knowledge, attitudes, and practice

BACKGROUND: The benefits of smoking cessation among older people are well documented. Despite this, evidence suggests that older smokers are rarely engaged in smoking cessation efforts, and that existing tobacco dependence treatments require further tailoring to the specific needs of older smokers. This study assesses the knowledge, attitudes, and clinical practice of primary care clinicians in relation to addressing tobacco dependence among older people. METHODS: A cross-sectional survey of 427 NHS primary care clinicians in a large English city was conducted using modified version of a previously validated questionnaire. RESULTS: One hundred and seventy one clinicians (40 % response rate) completed the survey. While the majority (90.0 %) of respondents reported enquiring regularly about older patients’ smoking status, just over half (59.1 %) reported providing older patients with smoking cessation support. A lack of awareness in relation to the prevalence and impact of smoking in later life were apparent: e.g. only 47 % of respondents were aware of that approximately 10 life years are lost due to smoking related disease, and only 59 % knew that smoking can reduce the effectiveness of medication prescribed for conditions common in later life. Self-reported attendance at smoking-related training was significantly associated with proactive clinical practice. CONCLUSIONS: There is a need to improve clinicians’ knowledge, in relation to smoking and smoking cessation in older patients and to build clinician confidence in seizing teachable moments. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s12875-015-0317-7) contains supplementary material, which is available to authorized users

Afrikaans as Standaard Gemiddelde Europees:Wanneer ‘n lid uit sy taalarea beweeg

A recent trend in the study of Standard Average European is the extraterritorial perspective of examining the extent to which non-European languages have converged with this Sprachbund as a result of contact with one or more of its members. The present article complements this line of research in that it investigates the extent to which a European language has diverged from Standard Average European after leaving the linguistic area. The focus is on Dutch, a nuclear member of the Sprachbund, and Afrikaans, its colonial offshoot. The two languages are compared with respect to twelve of the most distinctive linguistic features of Standard Average European. Afrikaans is found to share ten of them with Dutch, including anticausative prominence and formally distinguished intensifiers and reflexives, and could therefore still be considered a core member of the Sprachbund, despite deviations in the expression of negative pronouns and the grammaticality of external possessor constructions. This relatively low degree of divergence may be attributed to the continuity from Settler Dutch to at least the variety of Afrikaans on which the standard language is based and to the important role that Dutch continued to play in the history of Afrikaans

Uptake of self-management education programmes for people with type 2 diabetes in primary care through the embedding package: a cluster randomised control trial and ethnographic study

Background Self-management education programmes are cost-effective in helping people with type 2 diabetes manage their diabetes, but referral and attendance rates are low. This study reports on the effectiveness of the Embedding Package, a programme designed to increase type 2 diabetes self-management programme attendance in primary care. Methods Using a cluster randomised design, 66 practices were randomised to: (1) a wait-list group that provided usual care for nine months before receiving the Embedding Package for nine months, or (2) an immediate group that received the Embedding Package for 18 months. ‘Embedders’ supported practices and self-management programme providers to embed programme referral into routine practice, and an online ‘toolkit’ contained embedding support resources. Patient-level HbA1c (primary outcome), programme referral and attendance data, and clinical data from 92,977 patients with type 2 diabetes were collected at baseline (months − 3–0), step one (months 1–9), step 2 (months 10–18), and 12 months post-intervention. An integrated ethnographic study including observations, interviews, and document analysis was conducted using interpretive thematic analysis and Normalisation Process Theory. Results No significant difference was found in HbA1c between intervention and control conditions (adjusted mean difference [95% confidence interval]: -0.10 [-0.38, 0.18] mmol/mol; -0.01 [-0.03, 0.02] %). Statistically but not clinically significantly lower levels of HbA1c were found in people of ethnic minority groups compared with non-ethnic minority groups during the intervention condition (-0.64 [-1.08, -0.20] mmol/mol; -0.06% [-0.10, -0.02], p = 0.004), but not greater self-management programme attendance. Twelve months post-intervention data showed statistically but not clinically significantly lower HbA1c (-0.56 [95% confidence interval: -0.71, -0.42] mmol/mol; -0.05 [-0.06, -0.04] %; p < 0.001), and higher self-management programme attendance (adjusted odds ratio: 1.13; 95% confidence interval: 1.02, 1.25; p = 0.017) during intervention conditions. Themes identified through the ethnographic study included challenges for Embedders in making and sustaining contact with practices and providers, and around practices’ interactions with the toolkit. Conclusions Barriers to implementing the Embedding Package may have compromised its effectiveness. Statistically but not clinically significantly improved HbA1c among ethnic minority groups and in longer-term follow-up suggest that future research exploring methods of embedding diabetes self-management programmes into routine care is warranted