Linda Bauld

Strong theory, flexible methods: Evaluating complex community-based initiatives

A growing number of countries are beginning to move from acknowledging the existence of health inequalities to developing policies to reduce them. Many of these policies consist of complex interventions, operating at a number of levels, which aim to make a positive contribution to health improvement in deprived communities. Evaluating the efficacy of such initiatives poses particular challenges for evaluation. This paper argues that there is real potential in applying a theory-based approach to the evaluation of complex community-based initiatives. Using practical examples from the national evaluation of Health Action Zones in England, the paper outlines the key components of such an approach and argues that theory-based evaluation can strengthen programme design and implementation, as well as promote policy and practice learning about the most effective interventions for health improvement. We conclude that sophisticated theory building social change mechanisms in community settings is essential if real learning is to be generated from concerted efforts to achieve social change.

Smoking prevalence and smoking cessation services for pregnant women in Scotland

BackgroundOver 20% of women smoke throughout pregnancy despite the known risks to mother and child. Engagement in face-to-face support is a good measure of service reach. The Scottish Government has set a target that by 2010 8% of smokers will have quit via NHS cessation services. At present less than 4% stop during pregnancy. We aimed to establish a denominator for pregnant smokers in Scotland and describe the proportion who are referred to specialist services, engage in one-to-one counselling, set a quit date and quit 4 weeks later.MethodsThis was a descriptive epidemiological study using routinely collected data supplemented by questionnaire information from specialist pregnancy cessation services.Results13266 of 52370 (25%) pregnant women reported being current smokers at maternity booking and 3133/13266 (24%) were referred to specialist cessation services in 2005/6. Two main types of specialist smoking cessation support for pregnant women were in place in Scotland. The first involved identification using self-report and carbon monoxide breath test for all pregnant women with routine referral (1936/3352, 58% referred) to clinic based support (386, 11.5% engaged). 370 (11%) women set a quit date and 116 (3.5%) had quit 4 weeks later. The second involved identification by self report and referral of women who wanted help (1195/2776, 43% referred) for home based support (377/1954, 19% engaged). 409(15%) smokers set a quit date and 119 (4.3%) had quit 4 weeks later. Cost of home-based support was greater. In Scotland only 265/8062 (3.2%) pregnant smokers identified at maternity booking, living in areas with recognised specialist or good generic services, quit smoking during 2006.ConclusionsIn Scotland, a small proportion of pregnant smokers are supported to stop. Poor outcomes are a product of current limitations to each step of service provision - identification, referral, engagement and treatment. Many smokers are not asked about smoking at maternity booking or provide false information. Carbon monoxide breath testing can bypass this difficulty. Identified smokers may not be referred but an opt-out referral policy can remove this barrier. Engagement at home allowed a greater proportion to set a quit date and quit, but costs were higher.

Quit attempts in response to smoke-free legislation in England

Objectives To determine whether Englands smoke-free legislation, introduced on 1 July 2007, influenced intentions and attempts to stop smoking. Design and setting National household surveys conducted in England between January 2007 and December 2008. The sample was weighted to match census data on demographics and included 10 560 adults aged 16 or over who reported having smoked within the past year. Results A greater percentage of smokers reported making a quit attempt in July and August 2007 (8.6%, n=82) compared with July and August 2008 (5.7%, n=48) (Fishers exact=0.022); there was no significant difference in the number of quit attempts made at other times in 2007 compared with 2008. In the 5 months following the introduction of the legislation 19% (n=75) of smokers making a quit attempt reported that they had done so in response to the legislation. There were no significant differences in these quit attempts with regard to gender, social grade or cigarette consumption; there was however a significant linear trend with increasing age (χ2=7.755, df=1, p<0.005). The prevalence of respondents planning to quit before the ban came into force decreased over time, while those who planned to quit when the ban came into force increased as the ban drew closer. Conclusion Englands smoke-free legislation was associated with a significant temporary increase in the percentage of smokers attempting to stop, equivalent to over 300 000 additional smokers trying to quit. As a prompt to quitting the ban appears to have been equally effective across all social grades.

Improving access to smoking cessation services for disadvantaged groups: a systematic review

BACKGROUND Smoking is a main contributor to health inequalities. Identifying strategies to find and support smokers from disadvantaged groups is, therefore, of key importance. METHODS A systematic review was carried out of studies identifying and supporting smokers from disadvantaged groups for smoking cessation, and providing and improving their access to smoking-cessation services. A wide range of electronic databases were searched and unpublished reports were identified from the national research register and key experts. RESULTS Over 7500 studies were screened and 48 were included. Some papers were of poor quality, most were observational studies and many did not report findings for disadvantaged smokers. Nevertheless, several methods of recruiting smokers, including proactively targeting patients on General Physicians registers, routine screening or other hospital appointments, were identified. Barriers to service use for disadvantaged groups were identified and providing cessation services in different settings appeared to improve access. We found preliminary evidence of the effectiveness of some interventions in increasing quitting behaviour in disadvantaged groups. CONCLUSIONS There is limited evidence on effective strategies to increase access to cessation services for disadvantaged smokers. While many studies collected socioeconomic data, very few analysed its contribution to the results. However, some potentially promising interventions were identified which merit further research.

Promoting Social Change: The Experience of Health Action Zones in England

When New Labour came to power in the UK in1997 it brought with it a strong commitment to reducing inequality and social exclusion. One strand of its strategy involved a focus on areabased initiatives to reduce the effects of persistent disadvantage. Health Action Zones (HAZs) were the first example of this type of intervention, and their focus on community-based initiatives to tackle the wider social determinants of health inequalities excited great interest both nationally and internationally. This article draws on findings from the national evaluation of the initiative. It provides an overview of the HAZ experience, and explores why many of the great expectations associated with HAZs at their launch failed to materialise. It suggests that, despite their relatively limited impact, it is best to consider that they made a good start in difficult circumstances rather than that they failed. As a result there are some important lessons to be learned about the role of complex community-based interventions in tackling seemingly intractable social problems for policy-makers, practitioners and evaluators.

A comparison of the effectiveness of group-based and pharmacy-led smoking cessation treatment in Glasgow

AIM To compare the characteristics and outcomes of users accessing pharmacy and group-based smoking treatment. DESIGN Observational study of administrative information linked with survey data. SETTING Glasgow, Scotland. PARTICIPANTS A total of 1785 service users who set a quit date between March and May 2007. INTERVENTION Smoking treatment services based in pharmacies providing one-to-one support, and in the community offering group support. MEASUREMENTS Routine monitoring data included information about basic demographic characteristics, deprivation category of residence, nature of intervention and smoking status at 4-week follow-up determined by carbon monoxide (CO) readings < or = 10. These data were supplemented by information about socio-economic status and smoking-related behaviours obtained from consenting service recipients by treatment advisers. FINDINGS In the pharmacy-based service 18.6 % of users (n = 1374) were CO-validated as a quitter at 4 weeks, compared with 35.5 % (n = 411) in the group-based service. In a multivariate model, restricted to participants (n = 1366) with data allowing adjustment for socio-demographic and behavioural characteristics and including interaction terms, users who accessed the group-based services were almost twice as likely (odds ratio 1.980; confidence interval 1.50-2.62) as those who used pharmacy-based support to have quit smoking at 4-week follow-up. CONCLUSIONS Specialist-led group-based services appear to have higher quit rates than one-to-one services provided by pharmacies but the pharmacy services treat many more smokers. More research is needed to determine what can be done to bring the success rates of pharmacy services up to those of specialist-led groups and how to expand access to group-based services.

Impact of UK National Health Service smoking cessation services: variations in outcomes in England

Objectives: To determine the extent to which UK National Health Service (NHS) smoking cessation services in England reach smokers and support them to quit at four weeks, and to identify which service and area characteristics contribute to observed outcomes. Design: Ordinary least squares regression was used to investigate local smoking outcomes in relation to characteristics of health authorities and their smoking cessation services. Setting: 76 health authorities (from a total of 99) in England from April 2000 to March 2001. Main outcome measures:Reach—number of smokers attending cessation services and setting a quit date as a percentage of the adult smoking population in each health authority. Absolute success—number of smokers setting a quit date who subsequently reported quitting at four weeks (not having smoked between two and four weeks after quit date). Cessation rate—number of smokers who reported quitting at four weeks as a percentage of those setting a quit date. Loss—percentage lost to follow up. Results: A range of service and area characteristics was associated with each outcome. For example, group support proved more effective than one to one interventions in helping a greater proportion of smokers to quit at four weeks. Services based in health action zones were reaching larger numbers of smokers. However, services operating in deprived communities achieved lower cessation rates than those in more prosperous areas. Conclusions: Well developed, evidence based NHS smoking cessation services, reflecting good practice, are yielding positive outcomes in England. However, most of the data are based on self reported smoking status at four weeks. It will be important to obtain validated data about continuous cessation over one year or more in order to assess longer term impact.

The parents' experience: coping with drug use in the family

The families of drug users are often overlooked in the planning and delivery of services. This paper is based on interviews with parents of heroin users and staff from a support agency that worked with families affected by drug use. Findings highlight the devastation parents experienced in learning that their child was using heroin, and the subsequent impact that this had on their lives. Accessing support from a specialist agency provided tangible benefits for parents. These included a reduced sense of isolation, an increased knowledge of drugs and drug-related issues, and greater empathy for their son or daughter. This resulted in an improved support network for the drug user. However, parents faced many obstacles in accessing support, not least a lack of awareness of their needs amongst appropriate agencies. The paper concludes by highlighting the need to develop further tailored interventions to support families affected by drug use, and to improve the knowledge and awareness of the issue among treatment agencies and a range of other relevant organizations.

Should smokers be offered assistance with stopping

Many governments are actively considering whether and how to provide their population with assistance with smoking cessation. Arguments have been raised against this, but these are often based on fallacies (e.g. most smokers stop without help so assistance is unnecessary). This editorial counters these fallacies so that a constructive debate can be had about the role of cessation assistance in the tobacco control strategies for a given population.

Protocol for the Proactive Or Reactive Telephone Smoking CeSsation Support (PORTSSS) trial

BackgroundTelephone quit lines are accessible to many smokers and are used to engage motivated smokers to make quit attempts. Smoking cessation counselling provided via telephone can either be reactive (i.e. primarily involving the provision of evidence-based information), or proactive (i.e. primarily involving repeated, sequenced calls from and interaction with trained cessation counsellors). Some studies have found proactive telephone counselling more effective and this trial will investigate whether or not proactive telephone support for smoking cessation, delivered through the National Health Service (NHS) Smoking Helpline is more effective or cost-effective than reactive support. It will also investigate whether or not providing nicotine replacement therapy (NRT), in addition to telephone counselling, has an adjunctive impact on smoking cessation rates and whether or not this is cost effective.MethodsThis will be a parallel group, factorial design RCT, conducted through the English national NHS Smoking Helpline which is run from headquarters in Glasgow. Participants will be smokers who call the helpline from any location in England and who wish to stop smoking. If 644 participants are recruited to four equally-sized trial groups (total sample size = 2576), the trial will have 90% power for detecting a treatment effect (Odds Ratio) of 1.5 for each of the two interventions: i) proactive versus reactive support and ii) the offer of NRT versus no offer. The primary outcome measure for the study is self-reported, prolonged abstinence from smoking for at least six months following an agreed quit date. A concurrent health economic evaluation will investigate the cost effectiveness of the two interventions when delivered via a telephone helpline.DiscussionThe PORTSSS trial will provide high quality evidence to determine the most appropriate kind of counselling which should be provided via the NHS Smoking Helpline and also whether or not an additional offer of cost-free NRT is effective and cost effective for smoking cessation.Trial Registration(clinicaltrials.gov): NCT00775944