Exploring mental health professionals' practice in relation to smoke-free policy within a mental health trust: a qualitative study using the COM-B model of behaviour

Perceived Barriers and Facilitators Regarding the Implementation of Gamification to Promote Physical Activity in the Neighborhood: Interview Study Among Intermediaries

BACKGROUND

In the Netherlands, neighborhood sport coaches (NSCs) play an important role as intermediaries in promoting physical activity (PA) in the neighborhood. Gamification is the use of game elements in nongame contexts; it can be implemented with or without technology and holds promise for promoting PA. NSCs infrequently make use of this option.

OBJECTIVE

This study aims to understand barriers to, and facilitators of, using gamification to promote PA, as perceived by NSCs.

METHODS

A total of 25 semistructured interviews were conducted with NSCs in the Netherlands. The interviews were audiotaped, transcribed, and analyzed by means of thematic analysis using ATLAS.ti (version 22; ATLAS.ti Scientific Software Development GmbH) software. The deductive coding was informed by the capability, opportunity, motivation, behavior model and the theoretical domains framework, complemented by inductive coding.

RESULTS

Barriers and facilitators identified as factors influencing the implementation of gamification were related to 7 themes. NSCs required technical, creative, and promotion skills; knowledge about existing gamification tools; and social support from their employer and professional network. Financial costs were identified as a barrier to the successful implementation of gamification. Lack of clarity regarding stakeholders' responsibility to implement gamification could further hamper implementation. In general, NSCs were positive about investing time in implementing gamification and expected positive effects from implementing it.

CONCLUSIONS

To overcome identified barriers, a clear overview of tools, best practices, and available subsidies must be created, a gamification network must be established, the responsibility of NSCs must be clarified, and guidance must be offered on the promotion of gamification.

Support Provided by Stop-Smoking Practitioners to Co-users of Tobacco and Cannabis: A Qualitative Study

INTRODUCTION

Co-use of tobacco and cannabis is highly prevalent among cannabis users and is associated with poorer tobacco cessation outcomes. This study explored the barriers and enablers influencing stop-smoking practitioners' ability to provide optimal support to co-users.

AIMS AND METHODS

Online semi-structured interviews were audio recorded. Interviewees (n = 20) were UK-based certified stop-smoking practitioners. An interview schedule informed by the "capability", "opportunity", "motivation" (COM-B) model was designed to explore participants' perceived barriers and enablers in better supporting co-users to achieve abstinence of both substances or tobacco harm reduction. The transcripts were analyzed using framework analysis.

RESULTS

Capability: Practitioners' lack of knowledge and skills undermines their delivery of smoking cessation interventions to co-users. Interestingly, when cannabis is used for medicinal reasons, practitioners feel unable to provide adequate support. Opportunity: Service recording systems play an important role in screening for co-use and supporting co-users. When responding to clients' specific needs and practitioners' uncertainties, a positive therapeutic relationship and a support network of peers and other healthcare professionals are needed. Motivation: supporting co-users is generally perceived as part of practitioners' roles but there are concerns that co-users are less likely to successfully stop smoking.

CONCLUSIONS

Practitioners are willing to support co-users, but their lack of knowledge and access to an appropriate recording system are barriers to doing so. Having a supportive team and a positive therapeutic relationship is perceived as important. Identified barriers can be mostly addressed with further training to improve tobacco cessation outcomes for co-users.

Outcomes Among People With Schizophrenia Participating in General-Population Smoking Cessation Treatment: An Observational Study

OBJECTIVE

People with schizophrenia are much more likely than others to smoke tobacco, raising risks of disease and premature mortality. These individuals are also less likely to quit successfully after treatment, but the few existing clinical and observational studies have been limited by small sample sizes, and have generally considered specialized treatment approaches. In this analysis, we examine outcomes, service use, and potential explanatory variables in a large sample of people with schizophrenia treated in a general-population cessation program.

METHOD

Our sample comprised 3,011 people with schizophrenia and 77,790 controls receiving free nicotine replacement therapy through 400 clinics and health centres. We analysed self-reported 7-day abstinence or reduction at 6-month follow-up, as well as the number of visits attended and self-reported difficulties in quitting. We adjusted for demographic, socioeconomic, and health variables, and used multiple imputation to address missing data.

RESULTS

Abstinence was achieved by 16.2% (95% confidence interval [CI], 14.5% to 17.8%) of people with schizophrenia and 26.4% (95% CI, 26.0% to 26.7%) of others (absolute difference = 10.2%; 95% CI, 8.5% to 11.9%; P < 0.001). After adjustment, this difference was reduced to 7.3% (95% CI, 5.4% to 9.3%; P < 0.001). Reduction in use was reported by 11.8% (95% CI, 10.3% to 13.3%) and 12.5% (95% CI, 12.2% to 12.8%), respectively; this difference was nonsignificant after adjustment. People with schizophrenia attended more clinic visits (incidence rate ratio [IRR] = 1.15, 95% CI = 1.12% to 1.18%, P < 0.001) and reported more difficulties related to "being around other smokers" (odds ratio [OR] = 1.28; 95% CI, 1.11% to 1.47%; P = 0.001).

CONCLUSION

There is abundant demand for tobacco cessation treatment in this population. Outcomes were substantially poorer for people with schizophrenia, and this difference was not explained by covariates. Cessation remained much better than for unaided quit attempts, however, and engagement was high, demonstrating that people with schizophrenia benefit from nonspecialized pharmacological treatment programs.

Individuals with long-term illness, disability or infirmity are more likely to smoke than healthy controls: An instrumental variable analysis

Despite the prevalence of smoking cessation programs and public health campaigns, individuals with long-term illness, disability, or infirmity have been found to smoke more often than those without such conditions, leading to worsening health. However, the available literature has mainly focused on the association between long-term illness and smoking, which might suffer from the possible bidirectional influence, while few studies have examined the potential causal effect of long-term illness on smoking. This gap in knowledge can be addressed using an instrumental variable analysis that uses a third variable as an instrument between the endogenous independent and dependent variables and allows the identification of the direction of causality under the discussed assumptions. Our study analyzes the UK General Household Survey in 2006, covering a nationally representative 13,585 households. We exploited the number of vehicles as the instrumental variable for long-term illness, disability, or infirmity as vehicle numbers may be related to illness based on the notion that these individuals are less likely to drive, but that vehicle number may have no relationship to the likelihood of smoking. Our results suggested that chronic illness status causes a significantly 28% higher probability of smoking. The findings have wide implications for public health policymakers to design a more accessible campaign around smoking and for psychologists and doctors to take targeted care for the welfare of individuals with long-term illnesses.

An application of the stress-diathesis model: A review about the association between smoking tobacco, smoking cessation, and mental health

Background

Worldwide, approximately 24% of all adults smoke, but smoking is up to twice as prevalent in people with mental ill-health. There is growing evidence that smoking may be a causal risk factor in the development of mental illness, and that smoking cessation leads to improved mental health.

Methods

In this scholarly review we have: (1) used a modern adaptation of the Bradford-Hill criteria to bolster the argument that smoking could cause mental ill-health and that smoking cessation could reverse these effects, and (2) by considering psychological, biological, and environmental factors, we have structured the evidence to-date into a stress-diathesis model.

Results

Our model suggests that smoking is a psychobiological stressor, but that the magnitude of this effect is mediated and modulated by the individual's diathesis to develop mental ill-health and other vulnerability and protective factors. We explore biological mechanisms that underpin the model, such as tobacco induced damage to neurological systems and oxidative stress pathways. Furthermore, we discuss evidence indicating that it is likely that these systems repair after smoking cessation, leading to better mental health.

Conclusion

Based on a large body of literature including experimental, observational, and novel causal inference studies, there is consistent evidence showing that smoking can negatively affect the brain and mental health, and that smoking cessation could reverse the mental ill-health caused by smoking. Our model suggests that smoking prevention and treatment strategies have a role in preventing and treating mental illness as well as physical illness.

Stages of the Smoke-Free Policy Implementation in a Psychiatric Hospital: Evolution, Effects, and Complications

Background: The Smoke-free Policy represents a challenge in mental health services. Aim: To compare the stages of a smoke-free policy in a psychiatric hospital, according to the prevalence of smokers, hospital admission acceptance by hospitalized people, psychiatric complications, and the prescription of psychotropic drugs. Methods: Cross-sectional study was conducted with a comparison before and after implementing the Smoke-free Policy in a psychiatric hospital. Secondary data were obtained in 2020 from the medical records of 573 discharged people from psychiatric hospitalizations between September 2017 and August 2018. Fisher's exact test and the Kruskal-Wallis test were applied. Results: In the transition stage, there were more hospitalizations by court order, discharge motivated by the patient's disruptiveness behavior, administration of psychotropic drugs before the schedule time, physical aggression, physical/chemical restraints, length of stay, and dosage of psychotropic drugs. After the ban, there was a reduction in discharges motivated by the patient's disruptiveness behavior and an increase in discharge due to improvement in psychiatric symptoms, less occurrence of anticipation or modification in the use of psychotropic drugs, and fewer attempts to escape, aggressiveness, and physical restraint. Conclusion: The implementation of the Smoke-free Policy has a positive impact on psychiatric hospitalizations, with an increase in discharge due to improvement in psychiatric symptoms and a reduction in discharges due to other reasons. However, the transition stage requires greater attention from the nursing team, as the moment of adaptation to new rules and routines is followed by a momentary worsened behavior of those hospitalized.

Use of the behaviour change wheel to improve everyday person-centred conversations on physical activity across healthcare

BACKGROUND

An implementation gap exists between the evidence supporting physical activity in the prevention and management of long-term medical conditions and clinical practice. Person-centred conversations, i.e. focussing on the values, preferences and aspirations of each individual, are required from healthcare professionals. However, many currently lack the capability, opportunity, and motivation to have these conversations. This study uses the Behaviour Change Wheel (BCW) to inform the development of practical and educational resources to help bridge this gap.

METHODS

The BCW provides a theoretical approach to enable the systematic development of behaviour change interventions. Authors followed the described eight-step process, considered results from a scoping review, consulted clinical working groups, tested and developed ideas across clinical pathways, and agreed on solutions to each stage by consensus.

RESULTS

The behavioural diagnosis identified healthcare professionals' initiation of person-centred conversations on physical activity at all appropriate opportunities in routine medical care as a suitable primary target for interventions. Six intervention functions and five policy categories met the APEASE criteria. We mapped 17 Behavioural Change Techniques onto BCW intervention functions to define intervention strategies.

CONCLUSIONS

This study uses the BCW to outline a coherent approach for intervention development to improve healthcare professionals' frequency and quality of conversations on physical activity across clinical practice. Time-sensitive and role-specific resources might help healthcare professionals understand the focus of their intervention. Educational resources aimed at healthcare professionals and patients could have mutual benefit, should fit into existing care pathways and support professional development. A trusted information source with single-point access via the internet is likely to improve accessibility. Future evaluation of resources built and coded using this framework is required to establish the effectiveness of this approach and help improve understanding of what works to change conversations around physical activity in clinical practice.

Facilitators and barriers for harm reduction after first use of novel nicotine delivery devices: a qualitative investigation of cigarette smokers

BACKGROUND

Novel nicotine delivery devices (NNDDs) are a safer alternative to combustible tobacco smoking. Understanding what factors can facilitate people who smoke to use NNDDs can inform intervention design and public health messaging. This study aims to explore the facilitators and barriers to NNDD use from the perspective of smokers without prior use, after trialling two NNDDs.

METHOD

UK adults who smoke combustible cigarettes (n = 11) were recruited from a larger quantitative study after trialling two NNDDs, an electronic cigarette and a heated tobacco product (order randomly allocated). Semi-structured interviews were conducted, transcribed and thematically analysed, using the COM-B model of behaviour and NVivo12 pro software.

RESULTS

Five main themes were identified: health knowledge, availability of and accessibility to NNDD products, cost, social acceptance, and NNDD use experience. There was curiosity and interest in the uptake and use of NNDDs, but the absence of centralised product information was identified as a barrier. Other themes were related to the design and functionality of the NNDD products. For example, the e-cigarette with its low maintenance was seen as easier to use than the heated tobacco product, which offered too short a single use duration and was described as 'cumbersome'. Throat discomfort and high anticipated cost were among additional barriers identified for both product types.

CONCLUSION

This study highlights the need for reliable objective information on the health effects of NNDDs compared with combustible cigarettes, which could facilitate their regular use. Product adjustment such as single use duration alignment with combustible cigarette smoking duration may encourage uptake. Interventions offering opportunity for experience of NNDD use and knowledge dissemination of NNDDs could increase motivation to adopt harm reducing behaviours as demonstrated in this study.

Perceptions of Community Health Workers (CHW) on barriers and enablers to care for people with psychosis in rural Mozambique: findings of a focus group discussion study using the Capability, Opportunity, Motivation and Behaviour framework (COM-B framework)

BACKGROUND

Psychotic disorders contribute significantly to the global disease burden by causing disability, impaired quality of life, and higher mortality in affected people compared with the general population. In rural settings, where there is limited or no access to healthcare, individuals living with psychotic disorders often seek support from Community Health Workers (CHWs). However, little is known about what CHWs know about psychosis and how they manage such cases. This study aimed to explore the CHWs perception of psychosis and their experiences and beliefs about the factors that might enable or hinder care-taking for patients with psychosis in rural settings in Mozambique.

METHODS

A qualitative study was conducted in rural districts of Maputo Province, a southern region of Mozambique, using six focus group discussions with participation of 79 CHWs. Thematic analysis was used informed by the Capabilities, Opportunities, Motivation and Behaviour framework (COM-B).

RESULTS

Nine primary themes were identified. Overall, CHWs perceived psychosis as treatable medical conditions and held a positive attitude about being part of the care-taking process of patients with psychosis in rural settings. Partnerships with key-stakeholders such as traditional healers, health care workers, and families, were perceived by CHWs as enablers to improve access to care in rural areas. However, stigma, myths, and lack of competencies to treat people with psychosis were perceived by CHWs as barriers for appropriate care.

CONCLUSION

CHWs, with adequate support, could play an important role in the care of patients with psychosis in rural settings, including identifying patients requiring care and referring them to appropriate healthcare professionals, and following up medicated patients with psychosis. Training of CHWs should consider inclusion of basic mental health care competencies.

A systematic review of mental health professionals, patients and carers' perceived barriers and enablers to supporting smoking cessation in mental health settings

Introduction

Evidence-based smoking cessation and temporary abstinence interventions to address smoking in mental health settings are available, but the impact of these interventions is limited.

Aims and Methods

We aimed to identify and synthesize the perceived barriers and enablers to supporting smoking cessation in mental health settings. Six databases were searched for articles reporting the investigation of perceived barriers and enablers to supporting smoking cessation in mental health settings. Data were extracted and coded using a mixed inductive/deductive method to the theoretical domains framework, key barriers and enablers were identified through the combining of coding frequency, elaboration, and expressed importance.

Results

Of 31 included articles, 56 barriers/enablers were reported from the perspectives of mental healthcare professionals (MHPs), 48 from patient perspectives, 21 from mixed perspectives, and 0 from relatives/carers. Barriers to supporting smoking cessation or temporary abstinence in mental health settings mainly fell within the domains: environmental context and resources (eg, MHPs lack of time); knowledge (eg, interactions around smoking that did occur were ill informed); social influences (eg, smoking norms within social network); and intentions (eg, MHPs lack positive intentions to deliver support). Enablers mainly fell within the domains: environmental context and resources (eg, use of appropriate support materials) and social influences (eg, pro-quitting social norms).

Conclusions

The importance of overcoming competing demands on staff time and resources, the inclusion of tailored, personalized support, the exploitation of patients wider social support networks, and enhancing knowledge and awareness around the benefits smoking cessation is highlighted.

Implications

Identified barriers and enablers represent targets for future interventions to improve the support of smoking cessation in mental health settings. Future research needs to examine the perceptions of the carers and family/friends of patients in relation to the smoking behavior change support delivered to patients.

Health Professionals' Views on Lifestyle Advice Delivery to Teenage and Young Adult Cancer Patients: A Qualitative Study

BACKGROUND

Many health professionals working with teenage and young adult cancer patients (TYA-HPs) do not provide advice on physical activity, dietary intake, smoking cessation, and alcohol consumption as part of routine cancer care.

OBJECTIVE

The aim of this study was to understand TYA-HPs' perspectives on the provision of health behavior advice and preferences on an intervention to help develop their health promotion skills.

METHODS

In-depth, semistructured interviews were conducted with 26 TYA-HPs (12 nurses, 8 clinicians, and 6 allied health professionals) whose average time working with teenage and young adult (TYA) cancer patients was 8 years. Each interview followed the same semistructured guide, which was based upon constructs of the COM-B model of behavior change (capability, physical opportunity, social opportunity, reflective motivation, and automatic motivation), transcribed verbatim, and analyzed using the Framework analysis.

RESULTS

Overall, TYA-HPs recognized the value and importance of promoting health behaviors but felt that their capability to provide health behavior advice was limited by the availability of, and access to, good-quality evidence linking health behavior to cancer outcomes. The TYA-HPs expressed confusion over professional responsibility to provide choices.

CONCLUSIONS

The TYA-HPs recognize health behavior promotion to be a core part of TYA cancer care but feel ill-equipped to provide such advice to patients.

IMPLICATIONS FOR PRACTICE

Mapped to constructs of the COM-B model of behavior, these findings suggest that TYA-HPs would benefit from cross-multidisciplinary team support for improved access to TYA-specific resources covering key health behaviors and skills-based training on delivering lifestyle advice.

What the guide does not tell you: reflections on and lessons learned from applying the COM-B behavior model for designing real life interventions

Substantial inconsistency exists in the effectiveness of existing interventions to improve heart failure (HF) self-care, which can be partially explained by the fact that self-management interventions often lack theoretical models that underpin intervention development. The COM-B behavior model is a comprehensive theoretical framework that can be used to develop effective, theory-based interventions. The aim of this article is to highlight the challenges and practical solutions when applying the COM-B model to HF self-care, in order to provide useful support for researchers intending to use the model for designing behavior change interventions. "The Behaviour Change Wheel" handbook provides a step-by-step guide to understand and change behavior. When following the guide, some practical and methodological challenges were encountered. Lessons learnt to overcome these challenges are reported. Although the handbook is a comprehensive guide for designing behavior change interventions, a number of challenges arose. For example, the descriptions provided in the guide were not always sufficient to make solid judgments on how to categorize determinants; narrowing down intervention possibilities to a manageable number and prioritizing potential behavior change techniques over others involved a certain amount of subjectivity in an otherwise highly systematic and structured approach. For the encountered challenges, solutions are provided to illustrate how the model was applied practically to design theory-based behavior change interventions. This article provides a useful reference for researchers' use of the COM-B behavior model, as it outlines challenges that may occur and potential solutions to overcome them.

Views about integrating smoking cessation treatment within psychological services for patients with common mental illness: A multi-perspective qualitative study

BACKGROUND

Tobacco smoking rates are significantly higher in people with common mental illness compared to those without. Smoking cessation treatment could be offered as part of usual outpatient psychological care, but currently is not.

OBJECTIVE

To understand patient and health care professionals' views about integrating smoking cessation treatment into outpatient psychological services for common mental illness.

DESIGN

Qualitative in-depth interviews, with thematic analysis.

PARTICIPANTS

Eleven Improving Access to Psychological Therapies (IAPT) psychological wellbeing practitioners (PWPs), six IAPT patients, and six stop smoking advisors were recruited from English smoking cessation, and IAPT services.

RESULTS

Patients reported psychological benefits from smoking, and also described smoking as a form of self-harm. Stop smoking advisors displayed therapeutic pessimism and stigmatizing attitudes towards helping people with mental illness to quit smoking. PWPs have positive attitudes towards smoking cessation treatment for people with common mental illness. PWPs and patients accept evidence that smoking tobacco may harm mental health, and quitting might benefit mental health. PWPs report expertise in helping people with common mental illness to make behavioural changes in the face of mood disturbances and low motivation. PWPs felt confident in offering smoking cessation treatments to patients, but suggested a caseload reduction may be required to deliver smoking cessation support in IAPT.

CONCLUSIONS

IAPT appears to be a natural environment for smoking cessation treatment. PWPs may need additional training, and a caseload reduction. Integration of smoking cessation treatment into IAPT services should be tested in a pilot and feasibility study.

PATIENT OR PUBLIC CONTRIBUTION

Service users and members of the public were involved in study design and interpretation of data.

Improving case detection of tuberculosis in hospitalised Kenyan children-employing the behaviour change wheel to aid intervention design and implementation

BACKGROUND

The true burden of tuberculosis in children remains unknown, but approximately 65% go undetected each year. Guidelines for tuberculosis clinical decision-making are in place in Kenya, and the National Tuberculosis programme conducts several trainings on them yearly. By 2018, there were 183 GeneXpert® machines in Kenyan public hospitals. Despite these efforts, diagnostic tests are underused and there is observed under detection of tuberculosis in children. We describe the process of designing a contextually appropriate, theory-informed intervention to improve case detection of TB in children and implementation guided by the Behaviour Change Wheel.

METHODS

We used an iterative process, going back and forth from quantitative and qualitative empiric data to reviewing literature, and applying the Behaviour Change Wheel guide. The key questions reflected on included (i) what is the problem we are trying to solve; (ii) what behaviours are we trying to change and in what way; (iii) what will it take to bring about desired change; (iv) what types of interventions are likely to bring about desired change; (v) what should be the specific intervention content and how should this be implemented?

RESULTS

The following behaviour change intervention functions were identified as follows: (i) training: imparting practical skills; (ii) modelling: providing an example for people to aspire/imitate; (iii) persuasion: using communication to induce positive or negative feelings or stimulate action; (iv) environmental restructuring: changing the physical or social context; and (v) education: increasing knowledge or understanding. The process resulted in a multi-faceted intervention package composed of redesigning of child tuberculosis training; careful selection of champions; use of audit and feedback linked to group problem solving; and workflow restructuring with role specification.

CONCLUSION

The intervention components were selected for their effectiveness (from literature), affordability, acceptability, and practicability and designed so that TB programme officers and hospital managers can be supported to implement them with relative ease, alongside their daily duties. This work contributes to the field of implementation science by utilising clear definitions and descriptions of underlying mechanisms of interventions that will guide others to do likewise in their settings for similar problems.

'Quit During COVID-19'-staying smokefree in mental health in-patient settings

Cigarette smoking is one of the main preventable causes of cancers globally. At this time of global emergency, mental health professionals all over the world are joining hands with the public health and other healthcare communities to focus on acute measures to save lives from COVID-19. This has been particularly challenging in mental health hospital settings where numerous additional factors need to be considered, including difficulties of implementing social distancing, potential impacts of social isolation, increased stress levels and implications of all this on smoking. In this article, we will briefly discuss the prevalence of smoking in mental health patients, especially in those in mental health hospital settings and also what is the possible impact of COVID-19 pandemic in these people. Then we will go through the main reasons as to why encouraging smoking cessation in mental health patients is so important and measures we can take for supporting mental health patients quit smoking even during COVID-19 times. The smoking cessation interventions have a direct bearing on preventing future cancers and achieving smoking cessation among cancer patients in this already disadvantaged group.

Mental health professionals' perceptions, judgements and decision-making practices regarding the use of electronic cigarettes as a tobacco harm reduction intervention in mental healthcare: A qualitative focus group study

BACKGROUND

Smoking prevalence remains significantly higher among individuals with mental health conditions compared with the general population. Tobacco harm reduction (THR) in the form of replacing cigarettes for electronic cigarettes (ECs) is an alternative approach which may prove useful for these smokers who find it difficult to quit. Exploring how mental health professionals' (MHPs) perceive ECs, and how these influence decision making regarding their use in clinical settings is essential to determine the feasibility of incorporating ECs into the treatment pathway.

METHODS

We conducted six focus groups between March and August 2017. A total of 39 MHPs were recruited from mental healthcare services in England. Discussions were guided by a semi-structured guide, and responses were recorded, transcribed and coded using thematic framework analysis.

RESULTS

MHPs generally adopt a risk-averse approach when judging the safety and suitability of ECs. Risk-aversion was influenced by perceived obscurity surrounding ECs and THR, as well as high exposure to adverse and unreliable information regarding ECs, and perceived analogies between ECs and conventional cigarettes. Some MHPs adopt a pragmatic approach when making decisions based on THR and EC use in daily practice by considering the context of treatment and patient circumstances. However, this is often accompanied by a high degree of caution and misconceptions which limits the potential benefit this intervention could have in mental healthcare settings.

CONCLUSION

Improved dissemination of national guidance and scientific literature regarding THR and ECs is essential in mental healthcare to eliminate misconceptions and better inform MHPs evidence-based decision-making practices.