Faculty development in tobacco cessation: training health professionals and promoting tobacco control in developing countries

Education for Tobacco Use Disorder Treatment: Current State, Evidence, and Unmet Needs

Background

Tobacco use is undertreated in the medical setting. One driver may be inadequate tobacco use disorder treatment (TUDT) training for clinicians in specialties treating tobacco-dependent patients.

Objective

We sought to evaluate the current state of TUDT training for diverse professionals and how these skills are assessed in credentialing exams.

Methods

We performed a focused review of current educational practices, evidence-based strategies, and accreditation exam contents focused on TUDT.

Results

Among medical students, participants in reviewed studies reported anywhere from 45 minutes to 3 hours of TUDT training throughout their 4-year programs, most often in the form of didactic sessions. Similarly, little TUDT training was reported at the post-graduate (residency, fellowship, continuing medical education) levels, and reported training was typically delivered as time-based (expected hours of instruction) rather than competency-based (demonstration of mastery) learning. Multiple studies evaluated effective TUDT curricula at varied stages of training. More effective curricula incorporated longitudinal sessions and active learning, such as standardized patient encounters or proctored patient visits. Knowledge of TUDT is minimally evaluated on certification exams. For example, the American Board of Internal Medicine blueprint lists TUDT as <2% of one subtopic on both the internal medicine and pulmonary exams.

Conclusion

TUDT training for most clinicians is minimal, does not assess competency, and is minimally evaluated on certification exams. Effective, evidence-based TUDT training incorporating active learning should be integrated into medical education at all levels, with attention paid to inclusion on subsequent certifying exams.

Effectiveness of Medical Student Counseling for Hospitalized Patients Addicted to Tobacco (MS-CHAT): a Randomized Controlled Trial

BACKGROUND

Low-middle-income countries face an enormous burden of tobacco-related illnesses. Counseling for tobacco cessation increases the chance of achieving quit outcomes, yet it remains underutilized in healthcare settings.

OBJECTIVE

We tested the hypothesis that utilizing trained medical students to counsel hospitalized patients who use tobacco will lead to an increase in patient quit rates, while also improving medical student knowledge regarding smoking cessation counseling.

DESIGN

Investigator-initiated, two-armed, multicenter randomized controlled trial conducted in three medical schools in India.

PARTICIPANTS

Eligibility criteria included age 18-70 years, active admission to the hospital, and current smoking.

INTERVENTION

A medical student-guided smoking cessation program, initiated in hospitalized patients and continued for 2 months after discharge.

MAIN MEASURES

The primary outcome was self-reported 7-day point prevalence of smoking cessation at 6 months. Changes in medical student knowledge were assessed using a pre- and post-questionnaire delivered prior to and 12 months after training.

KEY RESULTS

Among 688 patients randomized across three medical schools, 343 were assigned to the intervention group and 345 to the control group. After 6 months of follow up, the primary outcome occurred in 188 patients (54.8%) in the intervention group, and 145 patients (42.0%) in the control group (absolute difference, 12.8%; relative risk, 1.67; 95% confidence interval, 1.24-2.26; p < 0.001). Among 70 medical students for whom data was available, knowledge increased from a mean score of 14.8 (± 0.8) (out of a maximum score of 25) at baseline to a score of 18.1 (± 0.8) at 12 months, an absolute mean difference of 3.3 (95% CI, 2.3-4.3; p < 0.001).

CONCLUSIONS

Medical students can be trained to effectively provide smoking cessation counseling to hospitalized patients. Incorporating this program into the medical curriculum can provide experiential training to medical students while improving patient quit rates.

TRIAL REGISTRATION

URL: http://www.

CLINICALTRIALS

gov . Unique identifier: NCT03521466.

An Effective Strategy to Activate Physicians to Promote High Cardiovascular Risk Patients to Quit Smoking

BACKGROUND

Adult patients cared for by cardiologists, neurologists, and diabetologists are highly vulnerable to cardiovascular diseases (CVDs), which are worsened by smoking. In the past, physicians of these three specialties at major hospitals in Taiwan always referred patients to family medicine and chest medicine departments for smoking cessation programs. However, the participation rate in these programs was unsatisfactory.

OBJECTIVES

To encourage cardiologists, neurologists, and diabetologists to provide smoking cessation treatment services (SCTSs) to their patients through an annual contest.

METHODS

Sequential expert meetings, group training, a contest to reward service quantity and abstinence rate, and an annual awards ceremony were held over the past 3 years.

RESULTS

More than 350 cardiologists, neurologists, and diabetologists were certified to provide SCTSs, and in the second half of 2020, 3716 high CVD risk patients entered smoking cessation treatment programs, with an abstinence rate exceeding 30% at 3 months.

CONCLUSIONS

The strategy used in this study was effective in overcoming physician inertia to provide SCTSs and encourage high CVD risk smokers to quit smoking.

The Need for Nationwide Electronic Cigarette Smoking Cessation Curricula Across the Healthcare Spectrum

Using electronic nicotine delivery systems (ENDS) has become a stepping stone for smokers in their cessation of tobacco use. Students within Doctor of Pharmacy and other health care programs have expressed varying responses as to how likely they are to recommend ENDS based on their knowledge of these devices. Because the amount of education on these products provided by PharmD programs varies, one study shows student pharmacists were less likely to recommend the use of ENDS to current cigarette smokers. This commentary suggests why some student pharmacists support such recommendations and therefore require more adequate ENDS education to better equip themselves for future patient education counseling sessions.

The extent of formal tobacco cessation training received by student health professionals and the prevalence of tobacco use among them: a cross-sectional study

Background: Advice from health care professionals (HCPs) is critical for tobacco prevention and cessation efforts. The academic curricula for health care professional students (HCS) lack comprehensive training in assisting patients in tobacco cessation. Tobacco use among HCP’s deters them from giving proper tobacco prevention and cessation guidance. The objective of this study was to determine the prevalence and determinants of tobacco consumption in third-year students of four health care disciplines (medical, dental, pharmacy, and nursing) and to assess their undergraduate education on tobacco control and cessation. Methods:  A web-based survey (response rate 84.4%) employing the Global Health Professions Student Survey (GHPSS) questionnaire; n= 838; [20.89 (SD± 0.94) years] was conducted in Mysore, India. A descriptive, comparative and multivariate analysis was performed. Results: The number of students who received formal training in smoking cessation approaches was only 14.04%. In total, two-thirds of medical students, compared to 38.9% of dental, 29.7% of pharmacy, and 11.40 % of nursing students, learned “the reasons why people smoke” as a part of their formal training. However, only less than a quarter of the study population were aware of the role of antidepressants in nicotine cessation medications. The total prevalence of tobacco use was 28.9%. A total of 37.72% wanted to quit smoking, while a mere 1.2% had sought any professional help to do so. Conclusions: Tobacco use in HCS, apart from personal health risks to themselves, may potentially affect their future commitment to support patients in tobacco cessation. There is a need for further research into tobacco prevention and cessation programs tailored to the needs of student groups. There is a need for an updated curriculum for tobacco cessation strategies and more research into better cessation strategies.

The extent of formal tobacco cessation training received by student health professionals and the prevalence of tobacco use among them: a cross-sectional study

Background: Advice from health care professionals (HCPs) is critical for tobacco prevention and cessation efforts. The academic curricula for health care professional students (HCS) lack comprehensive training in assisting patients in tobacco cessation. Tobacco use among HCP’s deters them from giving proper tobacco prevention and cessation guidance. The objective of this study was to determine the prevalence and determinants of tobacco consumption in third-year students of four health care disciplines (medical, dental, pharmacy, and nursing) and to assess their undergraduate education on tobacco control and cessation. Methods:  A web-based survey (response rate 84.4%) employing the Global Health Professions Student Survey (GHPSS) questionnaire; n= 838; [20.89 (SD± 0.94) years] was conducted in Mysore, India. A descriptive, comparative and multivariate analysis was performed. Results: The number of students who received formal training in smoking cessation approaches was only 14.04%. In total, two-thirds of medical students, compared to 38.9% of dental, 29.7% of pharmacy, and 11.40 % of nursing students, learned “the reasons why people smoke” as a part of their formal training. However, only less than a quarter of the study population were aware of the role of antidepressants in nicotine cessation medications. The total prevalence of tobacco use was 28.9%. A total of 37.72% wanted to quit smoking, while a mere 1.2% had sought any professional help to do so. Conclusions: Tobacco use in HCS, apart from personal health risks to themselves, may potentially affect their future commitment to support patients in tobacco cessation. There is a need for further research into tobacco prevention and cessation programs tailored to the needs of student groups. There is a need for an updated curriculum for tobacco cessation strategies and more research into better cessation strategies.

Prevalence of Smoking among Medical Students in a Tertiary Care Teaching Hospital

Introduction:

Tobacco smoking is one of the most important preventable risk factors for non-communicable diseases. It has been seen that medical students have a higher frequency of smoking compared to the general population. This study aims to determine the prevalence of smoking among third-year medical students in a tertiary care teaching hospital in Nepal.

Methods:

This descriptive cross-sectional study was conducted among the hospital’s third-year undergraduate medical students over a four-month period (October 2019 to January 2020). Ethical clearance was received from the Institutional Review Committee of Kathmandu Medical College and Teaching Hospital. The whole sampling technique was used to collect data. The Global Health Professional Students Survey questionnaire was used to collect data. Data analysis was done in the statistical package for social sciences.

Results:

The prevalence of current smoking among selected medical students of Kathmandu Medical College and Teaching Hospital is 34 (30.1%), majority male 26 (23%). Fifty-six (49.4%) of them had ever smoked cigarettes in their life, and 27 (23.9%) had their first cigarette in late adolescence. The number of students who used other forms of tobacco was comparatively lower i.e. 6 (5.3%). Many of the students 53 (46.9%) were exposed to second-hand smoke both at home and in public, while 18 (15.9) exposed only at public places, and 6 (5.3%) only at home.

Conclusions:

Our study has concluded that there is a notable prevalence of smoking among the participants. This points to the need for specific training sessions in their clinical years about smoking cessation for themselves and regarding counseling for patients.

The Effectiveness of Tobacco Dependence Education in Health Professional Students' Practice: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The objective of this study was to perform a systematic review to examine the effectiveness of tobacco dependence education versus usual or no tobacco dependence education on entry-level health professional student practice and client smoking cessation. Sixteen published databases, seven grey literature databases/websites, publishers’ websites, books, and pertinent reference lists were searched. Studies from 16 health professional programs yielded 28 RCTs with data on 4343 healthcare students and 3122 patients. Two researchers independently assessed articles and abstracted data about student knowledge, self-efficacy, performance of tobacco cessation interventions, and patient smoking cessation. All forms of tobacco were included. We did not find separate interventions for different kinds of tobacco such as pipes or flavoured tobacco. We computed effect sizes using a random-effects model and applied meta-analytic procedures to 13 RCTs that provided data for meta-analysis. Students’ counseling skills increased significantly following the 5As model (SMD = 1.03; 95% CI 0.07, 1.98; p < 0.00001, I² 94%; p = 0.04) or motivational interviewing approach (SMD = 0.90, 95% CI 0.59, 1.21; p = 0.68, I² 0%; p < 0.00001). With tobacco dependence counseling, 78 more patients per 1000 (than control) reported quitting at 6 months (OR 2.02; 95% CI 1.49, 2.74, I² = 0%, p = 0.76; p < 0.00001), although the strength of evidence was moderate or low. Student tobacco cessation counseling improved guided by the above models, active learning strategies, and practice with standardized patients.

Prevalence of tobacco use and perceptions of student health professionals about cessation training: results from Global Health Professions Students Survey

INTRODUCTION

Health professionals play an important role in providing advice to their patients about tobacco prevention and cessation. Health professionals who use tobacco may be deterred from providing cessation advice and counselling to their patients. We aimed to provide prevalence estimates of tobacco use among student health professionals and describe their attitudes towards tobacco cessation training.

METHODS

Country-wise aggregate data from the Global Health Professions Student Survey on 'current cigarette smoking' (smoking cigarettes on 1 or more days during the past 30 days), and 'current use of tobacco products other than cigarettes' (chewing tobacco, snuff, bidis, cigars or pipes, 1 or more days during the past 30 days) were analysed. For each WHO region, we estimated mean prevalence rates of tobacco use weighted by the population of the sampling frame and aggregate proportions for 'health professionals' role' and 'cessation training' indicators using 'metaprop' command on Stata V.11.

RESULTS

A total of 107 527 student health professionals participated in 236 surveys done in four health profession disciplines spanning 70 countries with response rates ranging from 40% to 100%. Overall, prevalence of smoking was highest in European countries (20% medical and 40% dental students) and the Americas (13% pharmacy to 23% dental students). Other tobacco use was higher in eastern Mediterranean (10%-23%) and European countries (7%-13%). In most WHO regions, ≥70% of the students agreed that health professionals are role models, and have a role in advising about smoking cessation to their patients and the public. Only ≤33% of all student health professionals in most WHO regions (except 80% dental students in the Eastern Mediterranean region) had received formal training on smoking cessation approaches and ≥80% of all students agreed that they should receive formal cessation training.

CONCLUSIONS

Tobacco control should take place together with medical educators to discourage tobacco use among student health professionals and implement an integrated smoking cessation training into health professions' curricula.

Influencing Readiness and Intentions to Offer Tobacco Dependence Treatment Through Training: King Hussein Cancer Center and Global Bridges Promoting an Underutilised Specialty in the Eastern Mediterranean Region

Introduction: Although tobacco dependence treatment (TDT) is key to tobacco control, there continues to be a shortage of services in the Eastern Mediterranean Region (EMR). Barriers to offering services include the lack of training and education.

Aims: To create a network of healthcare providers (HCPs) capable of advancing TDT, King Hussein Cancer Center – the regional host for Global Bridges in the EMR – developed, implemented, and evaluated a regional TDT training programme.

Methods: The programme employed a predisposing–enabling–reinforcing framework, and utilised a combination of learning techniques. The evidence-informed curriculum aimed to influence knowledge, confidence, and competence, and the evaluation mechanism was aligned with these aims.

Results and discussion: Training produced a 37% and 23% gain in knowledge and TDT-specific competencies, respectively. The majority of participants reported that the workshops enhanced confidence, and 72% reported intentions for positive change. Participants rated the workshops highly, and anticipated value from joining Global Bridges network. Immediate outcomes indicate success in advancing participants’ self-efficacy and readiness to treat. Intentions for positive change may potentially be the first step in modifying practice.

Conclusion: Capacity building in TDT could be the first step in meeting the need for trained HCPs through positively influencing knowledge, confidence, competence, and intentions.

Effectiveness of tobacco intervention education in health professional students' practice: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to examine the effectiveness of entry-level education on smoking cessation or prevention and tobacco-dependence interventions on health professional student practice in promoting client health and on client smoking cessation behaviors.The specific review question to be addressed: what is the effect of entry-level tobacco dependence education on: (1) health professional students' knowledge and skills and self-efficacy, (2) performance of tobacco prevention and cessation interventions, and (3) client smoking cessation behaviors?

Waterpipe tobacco smoking: The critical need for cessation treatment

BACKGROUND

Waterpipe use has spread globally, and has substantial negative health effects and nicotine dependence potential. A growing literature addresses cessation-related experiences of waterpipe users, but this literature has not been summarized nor is guidance available on developing and testing cessation interventions.

METHOD

Authors gathered key empirical papers on waterpipe cessation-related topics, including observational studies about users' perceived ability to quit, interest in quitting, quit rates, and cessation trials. Based on this review, recommendations are made to guide the development and rigorous evaluation of waterpipe cessation interventions.

RESULTS

Many users want to quit and make quit attempts, but are unsuccessful at doing so on their own; therefore, developing and testing waterpipe cessation interventions should be a priority for global tobacco control efforts. Early efforts have tested waterpipe cessation interventions designed for, or adapted from, cigarette smoking programs.

CONCLUSIONS

Waterpipe-specific cessation programs that address unique features of waterpipe smoking (e.g., its cultural significance, social uses, and intermittent use pattern) and characteristics and motivations of users who want to quit are needed. Recommendations are provided to move waterpipe cessation intervention development forward.

Advancing Tobacco Dependence Treatment Services in the Eastern Mediterranean Region: International collaboration for training and capacity-building

Tobacco use negatively affects health and is a major risk factor for non-communicable diseases (NCDs). Today, tobacco use ranks third among risk factors in North Africa and the Middle East in terms of disease burden. Despite the established need for these services, tobacco dependence treatment (TDT) services are still inadequate in the Eastern Mediterranean region (EMR). Among the main challenges hindering their expansion is the current lack of training opportunities. The provision of training and capacity-building-a key enabler of TDT-offers an excellent catalyst to launch TDT services in the region. This review discusses the need for TDT training in the EMR and describes a model for providing regional evidence-based training in line with international standards. The King Hussein Cancer Center in Amman, Jordan, is the regional host for Global Bridges, a worldwide TDT initiative. Using this model, they have trained 1,500 professionals and advocates from the EMR over the past three years.

Medical students' tobacco use and attitudes towards tobacco control

CONTEXT

Despite their important roles as future doctors in tobacco cessation counselling, the high prevalence of tobacco use among medical students may hinder them from advocating tobacco control policies and providing cessation counselling. Promoting this role among medical students is especially important in low- and middle-income countries with high burdens of tobacco use but limited resources for cessation programmes. This study examined the associations between medical students' tobacco use and their attitudes towards tobacco control policies and the roles of health professionals in the provision of tobacco cessation advice.

METHODS

This cross-sectional study included data from the large multi-country dataset generated by the Global Health Professions Student Survey, 2005-2008 (n = 36,533 medical students). Thirteen binary dependent variables related to medical students' attitudes towards tobacco control policies and the health professional's role in cessation counselling were examined using random-effects logistic regression, with tobacco use status as the key explanatory variable. Covariates included gender, receipt of cessation training, country-level and gender-specific smoking prevalence, region, and country income group.

RESULTS

Current tobacco use was consistently associated with less favourable attitudes towards tobacco control policy and cessation advice. Compared with never users, daily users were less likely to agree that the sale of tobacco products to adolescents should be banned (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.39-0.58) and that health professionals should routinely advise patients to quit smoking (OR = 0.48, 95% CI 0.41-0.52) or other forms of tobacco use (OR = 0.84, 95% CI 0.72-0.97). Daily users were less likely to agree that health professionals who smoke are less likely to advise patients to stop smoking (OR = 0.44, 95% CI 0.39-0.41).

CONCLUSIONS

Medical schools may benefit from a thorough re-evaluation of the scope of tobacco cessation training in their curricula in order to support students in smoking cessation and to shape their attitudes towards tobacco control. Targeting medical students who are current tobacco users in tobacco control efforts may be beneficial, given the cost-effectiveness of providing cessation advice.

Health policymakers' knowledge and opinions of physicians smoking and tobacco policy control in Lao PDR

BACKGROUND

In 2007, a regulation on smoke-free health facilities and institutions was adopted by the Lao government. Little is known about health policymakers' knowledge and opinions regarding tobacco policy control, including physicians' behaviour. This paper aims to describe the knowledge of Lao health policymakers and their opinions regarding physicians tobacco use and national smoking policy control.

METHODS

In 2007, we made a qualitative explorative study with data from a purposive sample of 18 key informants through semi-structured, face-to-face interviews. The key informants, who were heads of departments, directors of hospitals and directors of centres, mainly worked at the national level, and some provincial levels. Content analysis was used.

RESULTS

Policymakers perceived the inadequate implementation of a smoke-free regulation and policy as being a barrier and that the general public may not accept physicians smoking, since they are regarded as role models. Most of the respondents mentioned that regulations or laws related to control of smoking in health institutions are available in Laos, but they lacked detailed knowledge of them probably because regulations as well as the smoke-free policy documents were not widely disseminated. The respondents agreed that anti-smoking education should be integrated in the training curricula, especially in the medical schools, and that the provision of counselling on health consequences from smoking and methods of smoking cessation was important.

CONCLUSION

This study contributes to tobacco policy evidence and to knowledge regarding factors related to the uptake of evidence into policymaking. Dissemination and implementation of a tobacco control policy nationally, and integration of tobacco cessation training programs in the curricula were found to be productive approaches for improvement.

Training health professionals in smoking cessation

BACKGROUND

Cigarette smoking is one of the leading causes of preventable death world wide. There is good evidence that brief interventions from health professionals can increase smoking cessation attempts. A number of trials have examined whether skills training for health professionals can lead them to have greater success in helping their patients who smoke.

OBJECTIVES

To determine the effectiveness of training health care professionals in the delivery of smoking cessation interventions to their patients, and to assess the additional effects of training characteristics such as intervention content, delivery method and intensity.

SEARCH METHODS

The Cochrane Tobacco Addiction Group's Specialised Register, electronic databases and the bibliographies of identified studies were searched and raw data was requested from study authors where needed. Searches were updated in March 2012.

SELECTION CRITERIA

Randomized trials in which the intervention was training of health care professionals in smoking cessation. Trials were considered if they reported outcomes for patient smoking at least six months after the intervention. Process outcomes needed to be reported, however trials that reported effects only on process outcomes and not smoking behaviour were excluded.

DATA COLLECTION AND ANALYSIS

Information relating to the characteristics of each included study for interventions, participants, outcomes and methods were extracted by two independent reviewers. Studies were combined in a meta-analysis where possible and reported in narrative synthesis in text and table.

MAIN RESULTS

Of seventeen included studies, thirteen found no evidence of an effect for continuous smoking abstinence following the intervention. Meta-analysis of 14 studies for point prevalence of smoking produced a statistically and clinically significant effect in favour of the intervention (OR 1.36, 95% CI 1.20 to 1.55, p= 0.004). Meta-analysis of eight studies that reported continuous abstinence was also statistically significant (OR 1.60, 95% CI 1.26 to 2.03, p= 0.03).Healthcare professionals who had received training were more likely to perform tasks of smoking cessation than untrained controls, including: asking patients to set a quit date (p< 0.0001), make follow-up appointments (p< 0.00001), counselling of smokers (p< 0.00001), provision of self-help material (p< 0.0001) and prescription of a quit date (p< 0.00001). No evidence of an effect was observed for the provision of nicotine gum/replacement therapy.

AUTHORS' CONCLUSIONS

Training health professionals to provide smoking cessation interventions had a measurable effect on the point prevalence of smoking, continuous abstinence and professional performance. The one exception was the provision of nicotine gum or replacement therapy, which did not differ between groups.

Tobacco Control and Children: An International Perspective

Tobacco use currently claims >5 million deaths per year worldwide and this number is projected to increase dramatically by 2030. The burden of death and disease is shifting to low- and middle-income countries. Tobacco control initiatives face numerous challenges including not being a high priority in many countries, government dependence upon immediate revenue from tobacco sales and production, and opposition of the tobacco industry. Tobacco leads to environmental harms, exploitation of workers in tobacco farming, and increased poverty. Children are especially vulnerable. Not only do they initiate tobacco use themselves, but also they are victimized by exposure to highly toxic secondhand smoke. Awareness of tobacco adverse health effects is often superficial even among health professionals. The tobacco industry continues to aggressively promote its products and recognizes that children are its future. The tools and knowledge exist, however, to dramatically reduce the global burden of tobacco. In 2003 the World Health Organization adopted the Framework Convention on Tobacco Control. Aggressive tobacco control initiatives have been undertaken not only in high-income countries but also in less-wealthy countries such as Uruguay and Thailand. Stakeholders must come together in coordinated efforts and there must be a broad and sustained investment in global tobacco control.

Evidence-based practice or imperfect seduction? Developing capacity to respond effectively to drug-related problems

ISSUES

The last two or three decades have seen some valuable investment in workforce development. However, significant challenges remain in developing effective practice across various systems. Despite the relevance alcohol, tobacco and other drug use have for a range of staff across diverse organisations, adoption of cross-sector and collaborative effective practice is not widespread. The most common response involves a rather singular focus on strategies that develop practitioner knowledge and skills, with much less consideration given to the complex nature of the work environment and the belief systems of people who work in these environments.

APPROACH

This paper explores the barriers to and facilitators of effective practice, extending beyond the common focus on education and training initiatives. A model of capacity building is explored as a template to inform workforce and organisational development strategies.

KEY FINDINGS

Numerous barriers, outside education and training, must be considered in order to develop and maintain effective practice across various systems of prevention and treatment. The paper culminates with recommendations on how to overcome such challenges.

IMPLICATIONS

Workforce and organisational development must extend beyond education and training initiatives. Along with a focus on organisational and system factors, we must also attend to the marginalisation of people affected by drug use and associated pejorative attitudes.

CONCLUSION

Developing effective practice in the drug field involves changing the structures, and expected outcomes of these structures, in which people work, not just encouraging a few to use new ways of working in spite of the system.