Incident Learning in an Academic Radiation Oncology Practice during the COVID Era

PURPOSE/OBJECTIVE(S)

Incident learning is key to developing and maintaining quality and safety in healthcare. We aimed to characterize acute and sustained changes in incident submissions, point of incident origin/detection, severity and associated contributing factors during the COVID-19 pandemic.

HYPOTHESIS

The frequency and pattern of incident origin/detection were changed by altered workflows in response to COVID-19.

MATERIALS/METHODS

Events from our experienced incident learning system were analyzed between three 12-month intervals: pre-COVID (March 1, 2019 - February 29, 2020), early-COVID (March 1, 2020 - February 28, 2021), and late-COVID (March 1, 2021 - February 28, 2022). In addition to review by the department quality and safety committee, at least two physicians reviewed all incidents. Using descriptive statistics and chi-square test as applicable, we compared the reporting rates, incident severity, contributing factors, points of origin/ detection according to time the pre-specified time intervals prior to and during COVID.

RESULTS

See Table.

CONCLUSION

During COVID the number of reported incidents, particularly incidents reaching the patient, markedly declined. The number of incidents per patient increased with early-COVID altered workflows. This suggests that existing quality and safety checks were effective during early-COVID. The point of incident origin was similar across time periods. During early-COVID, the point of incident detection shifted to earlier points in the care pathway (e.g., pre-RT chart checks vs chart checks during RT), p<0.001. During late-COVID, as clinical workflows adapted, the point of detection shifted to later in the care pathway consistent with pre-COVID patterns. During COVID, workload was implicated in fewer incidents (in the setting of reduced treatment volumes), while communication and hand-offs were more frequently cited as contributing factors (in the setting of remote work). Our data supports the utility of consistent standards, minimizing inter-provider variations and maintaining robust quality and safety checks to optimize communication and safe patient care in radiation oncology.

The Need for Patience When Making Operational Changes to Address Quality

PURPOSE/OBJECTIVE(S)

There is increasing recognition in the value of systematically addressing operational issues to improve quality. However, the time necessary for these initiatives has not been well described. Here we report the time necessary to implement meaningful operational changes based on our institutional incident reporting system.

MATERIALS/METHODS

Our department has a robust quality improvement/assurance program where all team members are encouraged to report operational challenges through our "Good Catch Program". A multidisciplinary committee composed of MDs, physicists, dosimetrists, RTTs, RNs, administrators, and industrial engineers meets weekly to review new Good Catches and prior unresolved Good Catches. Each Good Catch was assigned a "Champion" to oversee responses and lead subsequent initiatives. The software tracked when a Good Catch is submitted, each time a note is added (reflecting an individual's comment or summary of group discussion), and when it is "closed". Good Catch closure occurred upon implementation of a change in workflow, development of a new policy, or decision to take no action. In cases where a change in workflow or policy was the consensus decision of the committee, the Good Catch was kept open and re-reviewed at subsequent weekly meetings until a new workflow was in place and relevant teams were onboarded.

RESULTS

From Jan 2015 - Dec 2022, 2748 Good Catches were reported (see Table). Most Good Catches were discussed at only one weekly multidisciplinary committee meeting and closed within 7 days of reporting (69%). For the 854 Good Catches that took >1 week to close, the median time to closure was 16 days (range 7-588 days). In general, the number of notes was higher for Good Catches that took longer to close; however, some Good Catches that closed rapidly had more than 10 notes in a short period of time and other Good Catches with lengthy time to closure had minimal resulting documentation (see Table). Most Good Catches were assigned a Champion who was an MD, Physicist, or RTT, and there was no significant difference in Champion assignments for those good catches that closed quickly (< 8 days) and those that had a longer duration to closure.

CONCLUSION

The majority of operational Good Catches are resolved quickly; speaking to the value of regular weekly multidisciplinary meetings. However, many operational issues require multiple discussion over many weeks and emphasizes that such efforts are challenging and require patience, dedication, and commitment to implement changes in workflow.

Assessing the Sustainability of Initiatives Aimed to Enhance Patient Safety Culture: A > 10-year Experience with Multifaceted Interventions

PURPOSE/OBJECTIVE(S)

Culture is a key factor in maintaining high-quality care. We have instituted a series of mutually-reinforcing initiatives aimed to improve operations, and patient and staff safety. We herein review the impact of these initiatives on our Patient Safety Culture over 14 years. We hypothesize that these initiatives can lead to sustained improvements in Culture.

MATERIALS/METHODS

In ≈ 2009, our department, with help of dedicated quality improvement coaches from our internal Division of Healthcare Engineering (with knowledge of Lean-Six Sigma and High Reliability methods and tools), instituted (and largely sustained) initiatives aimed to improve our operations, and to improve patient/staff safety; including: (a) daily multidisciplinary team huddles, (b) daily pre-planning/treatment peer review, (c) a robust Incident Learning System, (d) weekly meetings to review reported incidents, (e) monthly department-wide meetings to review the highlights from the weekly incident review meetings, (f) celebration/recognitions for staff participation and (g) leader Gemba walks. Culture was quantitatively assessed via the AHRQ (Agency for Healthcare Research and Quality) Patient Safety Culture Survey (with 51 questions) which was sent to the department every two years (2021 was skipped due to Covid). Changes in the summary survey results over time were assessed using 2-tailed chi-square.

RESULTS

Within 2-4 years of starting of our initiatives, there was an increase in the number of survey respondents, and an increase in the % of favorable responses (vs. pre-initiative data from 2009), for most comparisons (see Table with representative data). The % favorable responses plateaued in ≈ 2013-2015, and there was a non-significant decline in % favorable responses in later years (vs. the high scores in 2015).

CONCLUSION

A series of mutually reinforcing initiatives aimed to improve operations, and to improve patient/staff safety, can lead to improvements in Patient Safety Culture; and these improvements can be largely sustained over time. Some of the modest non-significant decline in later years may reflect staff changes, fatigue, increasing practice complexity, financial pressures, and/or Covid-related issues (in the 2022 survey). This speaks to the importance of maintaining quality/safety initiatives through transitions in leadership, staff and external stressors.

The Utility of Video-Based Pre-Treatment Peer Review in the COVID Era

Purpose/Objective(s)

Pre-treatment peer review has been suggested to be useful within Radiation Oncology. With the COVID-19 pandemic, our previously-applied face-to-face format was replaced with a video-based format. We herein quantify the usefulness of daily video-based peer review within a busy radiation oncology practice.

Materials/Methods

We have been using an internet-based format for our daily peer review since mid-March 2020. All cases in the department are reviewed prior to planning and a subset, typically stereotactic body radiotherapy (SBRT) cases, are reviewed twice: once for contours and once for the planned dose. A meeting participant collected data regarding attendance, case type, and recommendations made in the meetings. An anonymous survey was sent to all participants to assess their opinion of this daily meeting. The number and type of recommendations resulting from the video-based peer review were compared to the results of a similar review conducted in the pre-COVID (face-to-face) era using a two-tailed Fisher's exact test.

Results

From September 11, 2020 – December 23, 2020, data was gathered from 62 peer-review sessions. The mean number of attendees each day was 43 (range 32-60), including 9 MD faculty (range 4-12) and 7 MD residents (range 5-8). The average number of cases reviewed each day was 9 (range 3-17). In total, 533 cases were reviewed; 74% had no recommendations, 8% had mild, 15% had moderate, and 3% had major recommendations leading to significant changes in treatment planning. Among cases reviewed during the pre-COVID era 73% had none, 10% had mild, 10% had moderate, and 7% had major recommendations. The rate of major recommendations during the current video-format era is significantly decreased from before (3% vs 7%, P < 0.001). Twenty-nine participants responded to the survey. For the video-based peer review session, 97% reported that it adds value to the department, 83% reported that it provides an excellent learning environment, and 93% reported that it allows for a collegial debate/conversation.

Conclusion

Video-based peer review can be effective; 18% of case reviews resulted in moderate/major recommendations. While comparisons across time are imperfect, this is almost identical to the 17% observed in the pre-COVID (face-to-face) era, which is reassuring. However, the rate of major recommendations from the current video-format era were lower than in the pre-COVID (face-to-face) era, suggesting that the robustness of daily peer review may be reduced with video. Nevertheless, the majority of participants responding to the survey (83-97%) still find the overall process useful.

'They only smoke in the house when I'm not in': understanding the limited effectiveness of a smoke-free homes intervention

Background

Children’s second-hand smoke (SHS) exposure in the home is highest in socio-economically disadvantaged areas. Personalized household air-quality measurements can promote changes in smoking that reduce SHS exposure. The ‘First Steps 2 Smoke-free’ (FS2SF) intervention is the first to trial this approach delivered as part of health professionals’ routine work. This paper reports the findings of qualitative interviews with participants that explored their experiences of the intervention and why outcomes varied.

Methods

120 women were recruited from the NHS First Steps Programme, which supports disadvantaged mothers. They received either personalized feedback on their home air quality and advice on reducing SHS or standard SHS advice. Qualitative interviews with 15 mothers were analyzed thematically using the Capability, Opportunity, Motivation, Behaviour (COM-B) model.

Results

The intervention increased women’s capability to change home-smoking behaviour, through increasing awareness and salience of SHS risks to their children, and motivation to act. However, taking effective action was constrained by their limited social and environmental opportunities, including others’ smoking in the home.

Conclusions

The FS2SF intervention was ineffective as it was unable to fully address the precarious, complex life circumstances that make creating a smoke-free home particularly difficult for women experiencing intersecting dimensions of disadvantage.

PERPETRATION OF VIOLENCE BY FEMALE SEX WORKERS IN PAPUA NEW GUINEA: 'WE WILL CRUSH THEIR BONES'

There is a small but important body of literature on female sex workers' (FSWs) violence towards others, but little of that focused on low- and middle-income countries. Drawn from a larger biobehavioural study of FSWs in three cities in Papua New Guinea, we analyse the interviews from 19 FSWs who reported having perpetrated physical violence towards four major groups: (1) ex-husbands; (2) clients; (3) other sex workers and (4) other people (mainly women). Our study demonstrates that FSWs' use of violence arises from a complex set of social, material and gendered circumstances and cannot be addressed in isolation from other aspects of their lives.

Involving mosques in health promotion programmes: a qualitative exploration of the MCLASS intervention on smoking in the home

Second-hand smoke (SHS) exposure is high among UK Bangladeshi and Pakistani populations, reflecting higher male smoking prevalence and fewer home smoking restrictions than the general population. The Muslim Communities Learning About Second-hand Smoke (MCLASS) study explored the feasibility and acceptability of implementing SHS education in 14 UK mosques. Religious teachers (RTs) in seven intervention mosques were trained and provided with a culturally appropriate educational package. After the intervention, mosque leaders, RTs and congregants' experiences and perceptions of the intervention were explored through interviews and focus group discussions. Delivery of the intervention varied across mosques. Facilitators and barriers included: mosque diversity (congregation size, organizational structure, educational activities, women's role and involvement); degree of trust between researchers and personnel; and views on SHS. Most participants thought mosques' involvement in SHS health promotion was appropriate, but the perceived importance of SHS differed. We found that a health promotion programme delivered within Islamic religious settings that engages RTs in the process of facilitation, can be acceptable and feasible, but care must be taken to explore the culture and ethos of the institution, including its organizational structure, management committee, RTs and congregation.

Young people's exposure to point-of-sale tobacco products and promotions

OBJECTIVES

Point of sale (POS) displays are one of the most important forms of tobacco marketing still permitted in many countries. Reliable methods for measuring exposure to such displays are needed in order to assess their potential impact, particularly on smoking attitudes and uptake among young people. In this study we use a novel method for evaluating POS exposure based on young people's use of retail outlets and recall of tobacco displays and observational data on the characteristics of displays.

STUDY DESIGN

Observational audit of retail outlets (n = 96) and school-based pupil survey (n = 1482) in four Scottish communities reflecting different levels of social deprivation and urbanisation, conducted in 2013 before legislation to remove POS displays was implemented in supermarkets.

METHODS

Measures were taken of: visibility and placement of tobacco displays; internal and external advertising; display unit size, branding and design; visibility of pack warnings; proximity of tobacco products to products of potential interest to children and young people; pupils' self-reported frequency of visiting retail outlets; and pupils' recall of tobacco displays. Variation in POS exposure across social and demographic groups was assessed.

RESULTS

Displays were highly visible within outlets and, in over half the stores, from the public footway outside. Tobacco products were displayed in close proximity to products of interest to children (e.g. confectionery, in 70% of stores). Eighty percent of pupils recalled seeing tobacco displays, with those from deprived areas more likely to recall displays in small shops. When confectioners, tobacconists and newsagents (CTNs) and grocery/convenience stores (two of the outlet types most often visited by young people) were examined separately, average tobacco display unit sizes were significantly larger in those outlets in more deprived areas.

CONCLUSIONS

POS displays remain a key vector in most countries for advertising tobacco products, and it is important to develop robust measures of exposure. The data reported in this paper provide a baseline measure for evaluating the efficacy of legislation prohibiting such displays.

Does exposure to cigarette brands increase the likelihood of adolescent e-cigarette use? A cross-sectional study

OBJECTIVE

To examine the relationship between tobacco cigarette brand recognition, and e-cigarette use in adolescents.

DESIGN

Cross-sectional observational study.

SETTING

High schools in Scotland.

PARTICIPANTS

Questionnaires were administered to pupils in Secondary 2 (S2 mean age: 14.0 years) and Secondary 4 (S4 mean age: 15.9 years) across 4 communities in Scotland. An 86% response rate with a total sample of 1404 pupils was achieved.

MAIN OUTCOME MEASURES

Self-reported previous use of e-cigarettes and self-reported intention to try e-cigarettes in the next 6 months.

RESULTS

75% (1029/1377) of respondents had heard of e-cigarettes (69.5% S2, 81.1% S4), and of these, 17.3% (10.6% S2, 24.3% S4 n=1020) had ever tried an e-cigarette. 6.8% (3.7% S2, 10.0% S4 n=1019) reported that they intended to try an e-cigarette in the next 6 months. Recognition of more cigarette brands was associated with greater probability of previous e-cigarette use (OR 1.20, 99% CI 1.05 to 1.38) as was having a best friend who smoked (OR 3.17, 99% CI 1.42 to 7.09). Intention to try e-cigarettes was related to higher cigarette brand recognition (OR 1.41, 99% CI 1.07 to 1.87), hanging around in the street or park more than once a week (OR 3.78, 99% CI 1.93 to 7.39) and living in areas of high tobacco retail density (OR 1.20, 99% CI 1.08 to 1.34). Never having smoked was a protective factor for both future intention to try, and past e-cigarette use (OR 0.07, 99% CI 0.02 to 0.25; and OR 0.10, 99% CI 0.07 to 0.16, respectively).

CONCLUSIONS

Higher cigarette brand recognition was associated with increased probability of previous use and of intention to use e-cigarettes. The impact of tobacco control measures such as restricting point-of-sale displays on the uptake of e-cigarettes in young people should be evaluated.

E-cigarette marketing in UK stores: an observational audit and retailers' views

OBJECTIVES

To explore how e-cigarettes are being promoted at point of sale in the UK and how retailers perceive market trends.

SETTING

Fixed retail outlets subject to a ban on the display of tobacco products.

PARTICIPANTS

Observational audit of all stores selling tobacco products (n=96) in 4 Scottish communities, conducted over 2 waves 12 months apart (2013-2014), and qualitative interviews with small retailers (n=25) in 4 matched communities.

PRIMARY AND SECONDARY OUTCOME MEASURES

The audit measured e-cigarette display characteristics, advertising materials and proximity to other products, and differences by area-level disadvantage. Interviews explored retailers' perceptions of e-cigarette market opportunities and risks, and customer responses.

RESULTS

The number of e-cigarette point-of-sale display units and number of brands displayed increased between waves. E-cigarettes were displayed close to products of interest to children in 36% of stores. Stores in more affluent areas were less likely to have external e-cigarette advertising than those in deprived areas. Although e-cigarettes delivered high profit margins, retailers were confused by the diversity of brands and products, and uncertain of the sector's viability. Some customers were perceived to purchase e-cigarettes as cessation aids, and others, particularly low-income smokers, as a cheaper adjunct to conventional tobacco.

CONCLUSIONS

E-cigarette point-of-sale displays and number of brands displayed increased over 12 months, a potential cause for concern given their lack of regulation. Further scrutiny is needed of the content and effects of such advertising, and the potentially normalising effects of placing e-cigarettes next to products of interest to children.

quit4u: the effectiveness of combining behavioural support, pharmacotherapy and financial incentives to support smoking cessation

The 'quit4u' stop smoking service (SSS) was developed by National Health Service (NHS) Tayside for smokers in deprived areas of Dundee (UK). quit4u combined behavioural support and pharmacotherapy with financial incentives for each week that participants remained quit. A quasi-experimental study was undertaken with smokers using quit4u between 2009 and 2011 compared with smokers using SSSs in the rest of Scotland. The outcome measures were: number of quit attempts; quit rates at 1, 3 and 12 months; cost-effectiveness. Mechanisms of change were explored through quantitative and qualitative research that explored the views and experiences of service users and professionals involved in quit4u. The number of quit attempts made using SSSs in deprived areas of NHS Tayside increased by 44% between 2007 and 2010. quit4u had significantly higher quit rates at 1 month (49.9% versus 33.7%), 3 months (30.7% versus 14.2%) and 12 months (9.3% versus 6.5%) compared with similar smokers using other SSSs. The incremental cost per quitter was £2296. A combination of elements kept clients engaged and supported quit attempts: carbon monoxide (CO) tests, financial incentives, high-quality pharmacy support, rolling groups and greater varenicline use. quit4u may provide an effective and cost-effective model for engaging and supporting smokers in deprived areas to quit.

Male circumcision for HIV prevention in Papua New Guinea: a summary of research evidence and recommendations for public health following a national policy forum

In 2005, a clinical trial in South Africa found that circumcision of young men could reduce their risk of acquiring HIV (human immunodeficiency virus) infection by over 60%. In the following year, two more trials in Africa confirmed this finding, leading the World Health Organization to recommend male circumcision as a public health strategy for HIV prevention in high-incidence countries. In order to inform public health policy in Papua New Guinea (PNG), two major research projects were initiated with the goals of investigating the status of penile cutting practices and assessing understandings, acceptability, feasibility and cost-effectiveness of male circumcision for HIV prevention. In addition, behavioural surveillance surveys systematically asked questions on penile cutting practices and an ethnographic literature review informed historical perspectives of penile cutting in PNG. Key findings from these research activities were presented at a National Policy Forum on Male Circumcision for HIV Prevention held in Port Moresby in November 2011. The Forum made three key recommendations: (1) the formation of a joint National Department of HealthlNational AIDS Council Secretariat Policy Committee on male circumcision; (2) the establishment of an integrated harm reduction program; and (3) that future policy on wide-scale roll-out of male circumcision for HIV prevention in PNG be informed by a combination of data from (a) male circumcision intervention pilot programs and (b) research on the potential protective effect of other forms of penile cutting.

Invasive breast cancers detected by screening mammography: a detailed comparison of computer-aided detection-assisted single reading and double reading

To compare double reading plus arbitration for discordance, (currently best practice, (BP)) with computer-aided-detection (CAD)-assisted single reading (CAD-R) for detection of invasive cancers detected within BreastScreen Australia. Secondarily, to examine characteristics of cancers detected/rejected using each method. Mammograms of 157 randomly selected double-read invasive cancers were mixed 1:9 with normal cancers (total 1569), all detected in a BreastScreen service. Cancers were detected by two readers or one reader (C2 and C1 cancers, ratio 70:30%) in the program. The 1569 film-screen mammograms were read by two radiologists (reader A (RA) and reader B(RB)), with findings recorded before and after CAD. Discordant findings with BP were resolved by arbitration. We compared CAD-assisted reading (CAD-RA, CAD-RB) with BP, and CAD and arbitration contribution to findings. We correlated cancer size, sensitivity and mammographic density with detection methods. BP sensitivity 90.4% compared with CAD-RA sensitivity 86.6% (P = 0.12) and CAD-RB 94.3% (P = 0.14). CAD-RB specificity was less than BP (P = 0.01). CAD sensitivity was 93%, but readers rejected most positive CAD prompts. After CAD, reader's sensitivity increased 1.9% and specificity dropped 0.2% and 0.8%. Arbitration decreased specificity 4.7%. Receiving operator curves analysis demonstrated BP accuracy better than CAD-RA, borderline significance (P = 0.07), but not CAD-RB. Secondarily, cancer size was similar for BP and CAD-R. Cancers recalled after arbitration (P = 0.01) and CAD-R (P = 0.10) were smaller. No difference in cancer size or sensitivity between reading methods was found with increasing breast density. CAD-R and BP sensitivity and cancer detection size were not significantly different. CAD-R specificity was significantly lower for one reader.

An exploratory study of the perceived impact of raising the age of cigarette purchase on young smokers in Scotland

OBJECTIVES

To explore the perceived impact among a group of Scottish 16- and 17-year-old school leavers of the recent increase in age of sale of cigarettes (1 October 2007) from 16 to 18 years on their ability to purchase and access cigarettes.

STUDY DESIGN

Qualitative interviews with friendship pairs.

METHODS

Twelve paired qualitative interviews conducted in June 2008. Participants were 16- and 17-year-old early school leavers undertaking a work skills programme in Lothian who smoked at least one cigarette per week. Data were analysed thematically.

RESULTS

The increase in the age of sale affected participants' perceived ability to purchase cigarettes to differing extents. Three groups were identified: those who were unable to purchase cigarettes either before or after the change in the law, those who could purchase cigarettes before the change in the law but who found it very difficult to do so afterwards, and those who were relatively unaffected as they could purchase cigarettes both before and after the age was raised to 18 years, mostly from small corner shops. Smoking was embedded in participants' social lives and networks. Thus, there was only a limited impact upon their reported ability to access cigarettes due to the availability of alternative social sources of cigarettes from family, friends and others.

CONCLUSIONS

This exploratory study raises questions about the nature and extent of the impact of raising the age of sale on young smokers' ability to purchase and access cigarettes. The importance of alternative social sources of cigarettes highlights the need for further research to investigate whether the change in legislation had less of an impact on more disadvantaged adolescent smokers, as they are likely to have greater access to alternative sources from their family, friends and community.

Adults with late diagnosed PKU and severe challenging behaviour: a randomised placebo-controlled trial of a phenylalanine-restricted diet

BACKGROUND

Although early diagnosis and treatment in phenylketonuria (PKU) leads to excellent outcomes, a population of adults born before the introduction of newborn screening exists. They can have severe intellectual disabilities and behavioural problems, and are often dependent on full-time carers. Anecdotal evidence suggests that a diet that lowers blood phenylalanine concentration can have significant benefits upon behaviour.

METHODS

A prospective double-blind randomised placebo-controlled crossover trial of phenylalanine-restricted diet was performed in a group of 34 adults (aged 21-61 years, median 49) with late diagnosed PKU with severe challenging behaviour.

RESULTS

Only 17 completed the 60 week study: seven withdrew before the end of the baseline period; five withdrew during the first diet period; five withdrew during the second diet period (after moving into placebo phase). The mean (SD) blood phenylalanine was 1570 (222) micromol/l during baseline, 553(158) mumol/l during the active phase and 1444 (255) micromol/l during the placebo phase. In the 22 participants exposed to both active and placebo phases, no differences were demonstrated in behaviour assessed by the Aberrant Behavior Checklist and Vineland Adaptive Behavior Scales, behaviour diaries or on video analysis of direct observations. However, 76% of carers' comments were scored as positive during the active phase, compared with 54% during the placebo phase (chi(2) = 38.06, p<0.001).

CONCLUSIONS

There are significant challenges in studying people with intellectual disabilities and considerable difficulties in instituting phenylalanine-restricted diet in this population. However, if attempted, there are potential benefits to quality of life for the individuals with PKU and their carers.

Determinants of false positive recall in an Australian mammographic screening program

We conducted a case-control study (n=30128) to assess the importance of clinical (e.g., family history, age, hormone replacement therapy (HRT) use and duration) and service-related characteristics (e.g., time since introduction of Kodak MINR2000 film, year of screen) for false positive (FP) recall at BreastScreen Victoria, Australia. There was an age-adjusted upward trend in FP recall rates with year of screen at first (odds ratio (OR) 1.11, 95% confidence interval (95% CI) 1.08-1.13) and subsequent rounds (OR 1.04, 95% CI 1.01-1.06). In the multivariate analysis, the upward trend only remained for first round and age and family history also remained statistically significant at first round. At subsequent rounds the time since introduction of MINR2000, age, strong family history of breast cancer, use of HRT, recall at previous screen and previous screen at more than 27 months were all important predictors of FP recall. The rise in FP rates with year of screen at first round screening is of concern and may require further training of radiologists to improve confidence when viewing films when there a no films for comparison.

Evaluation of the organised mammographic screening programme in Australia

An organised approach to mammographic screening in Australia commenced in 1992 as a free service for asymptomatic women in the target age range 50-69 years and accessible to all women aged >/=40 years. Screening is performed by two-view mammography, women aged 50-69 years being sent reminders every 2 years for repeat screens. National Accreditation Standards have been agreed and BreastScreen Australia has developed mechanisms to monitor and report performance including systems and standards for data collection. The national report includes participation rates, small cancer detection rates and programme sensitivities. These indicate that BreastScreen Australia is meeting its accreditation standards with respect to most measures. Routinely collected outcome data reflect an increasing trend in the proportion of women receiving breast conserving surgery; a decline in the proportion of women diagnosed with ductal carcinoma in situ undergoing axillary dissection and an increasing use of combination therapies with a corresponding decrease in the use of hormonal therapy alone. There have been increases in breast cancer incidence and falls in mortality with the largest changes in women aged 50-69 years. As the BreastScreen Australia database is routinely linked in future to population cancer registries, the mortality reduction due to mammographic screening may be estimated more precisely.

"They're doing people a service"-qualitative study of smoking, smuggling, and social deprivation

OBJECTIVES

To examine the behaviour and attitudes related to smoking and contraband tobacco products among smokers in two socially deprived areas.

DESIGN

Cross sectional study with qualitative semistructured interviews, augmented by smokers' day grid.

SETTING

Two areas of socioeconomic deprivation in Edinburgh.

PARTICIPANTS

50 male and 50 female smokers aged 25-40 years randomly selected from general practitioners' lists from two health centres, each located in an area of deprivation.

RESULTS

Most smokers wanted to quit but felt unable to because of the importance of smoking in their daily routine and their addiction to nicotine. Strategies for maintaining consumption levels in the face of increasing cigarette prices and low income included purchasing contraband cigarettes and tobacco. Vendors were contacted through social networks, family, and friends as well as common knowledge of people and places, particularly pubs where contraband was available. Most users of contraband considered that smugglers were providing a valuable service. Purchasing contraband tobacco was viewed as rational in the face of material hardship. Many smokers criticised the government for its high tobacco taxation and the lack of local services to help them to stop smoking.

CONCLUSIONS

Smokers in deprived areas perceive a lack of support to help them to stop smoking. Cigarette and tobacco smuggling is therefore viewed positively by low income smokers as a way of dealing with the increasing cost of cigarettes. Smokers in areas of deprivation may thus show little support for tackling smuggling until more action is taken to deal with the material and personal factors that make it difficult for them to quit.

A computational model of information processing in the frontal cortex and basal ganglia

Performance on the Wisconsin Card Sort Test (WCST) of patients with schizophrenia, Parkinson's disease (PD), and Huntington's disease (HD) was simulated by a neural network model constructed on principles derived from neuroanatomic loops from the frontal cortex through the basal ganglia and thalamus. The model provided a computational rationale for the empirical pattern of perseverative errors associated with frontal cortex dysfunction and random errors associated with striatal dysfunction. The model displayed perseverative errors in performance when the gain parameter of the activation function in units representing frontal cortex neurons was reduced as an analog of reduced dopamine release. Random errors occurred when the gain parameter of the activation function in units representing striatal neurons was reduced, or when the activation level was itself reduced as an analog of a striatal lesion. The model demonstrated that the perseveration of schizophrenic, Huntington's, and demented Parkinsonian patients may be principally due to ineffective inhibition of previously learned contextual rules in the frontal cortex, while the random errors of Parkinson's and Huntington's patients are more likely to be due to unsystematic errors of matching in the striatum. The model also made specific, empirically falsifiable predictions that can be used to explore the utility of these putative mechanisms of information processing in the frontal cortex and basal ganglia.

Continuities and changes: teenage smoking and occupational transition

Rates of cigarette smoking among young people in the U.K. remain high and may be increasing. However, few studies have explored smoking behaviour during the mid- to late teens. This paper reports the third wave of a longitudinal study that followed 106 15-year-olds from their last compulsory year at school for 22 months. Using a mixture of qualitative and quantitative methods, the study shows that this is a period of considerable flux in smoking behaviour. Becoming a regular smoker is not a straightforward progressive process. The role of friendship groups and social context is highlighted. Smoking prevention programmes should be developed to meet the needs of young people in this transitional period.

Health related behavioural change in context: young people in transition

Post-modern theorists have highlighted the impacts of rapid social and economic change in lessening structural constraints, arguing that the concepts of "gender" and "social class" are now less useful in understanding people's life chances and choices. While the epochal nature of such changes has been questioned, increasing levels of individualisation and reflexivity have been widely recognised. Agency is prioritised and structural disembeddedness increasingly assumed: people are held to construct their identities and biographies reflexively from a diverse range of experiences and opportunities. When used in relation to understanding health related behaviours this theorising has led to an increasing focus upon the symbolic significance of consumption (and indeed risk) in defining lifestyles and identities. Here we report on the health related behaviours of 106 young people (15/16 yr) during their transition from school to employment, training or further education. This period is arguably central in the process of creating adult identities and accordingly should involve considerable lifestyle choice, reflexivity and symbolic consumption as identities are formed. By drawing on two rounds of data (semi-structured interviews and structured questionnaires) we consider how smoking and drinking behaviours related to the wider social transitions towards adulthood. We provide a situated account of health related behaviours which acknowledges both subjective experience and social location. We argue that the current challenge is to integrate the different levels of structural constraint and individual agency within the context of current rapid social and economic change and suggest that it is only through empirical investigation which embraces an analysis both at the level of structure and individual experience that the conditions of late modernity can be more thoroughly understood.

Healthy or druggy? Self-image, ideal image and smoking behaviour among young people

Recent research indicates that there is an important, though complex, relationship between the social image of smoking and young people's self- and aspirational images. This study explored how young people see themselves (self-image), how they would like to be (ideal image), and whether these differ according to age, gender and smoking status. Focus groups were used to elicit attributes which young people use to describe smoking and non-smoking images taken from fashion pages in youth magazines. These attributes were incorporated into a self-completion questionnaire which was administered to 897 young people from three age groups (12-13 years, 15-16 years and 18-19 years). The respondents rated their self- and ideal images on each of these attributes. Overall, there were few differences between the rank order of attributes by age, sex or smoking status. However, there were differences in the trait scores, with males and smokers tending to rate themselves more positively. The two traits which most clearly differentiated smokers and non-smokers were druggy/takes drugs (self- and ideal image) and healthy (self-image). It appears that smokers in general, and male smokers in particular, embraced certain dimensions of self- and aspirational image of which druggy, tough and tarty are signifiers. In contrast, the differences between female smokers and non-smokers were less consistent and differed with age. The implications for health promotion are discussed.

Girls, pecking order and smoking

Against a background of growing concern about the failure to reduce cigarette smoking amongst young people, particularly girls, this paper attempts to unravel the complex interrelationships between smoking, peer group structure and gender. We were particularly intrigued to explore a recent hypothesis in the literature that suggests that girls who smoke, far from lacking self-esteem, are more self-confident and socially skilled than their non-smoking peers. Sociometric and qualitative analyses revealed that smoking behaviour was indeed shaped by gender, and that the psychosocial processes involved in smoking uptake may be different for boys and than for girls. Peer group structure, consistently described by young people as hierarchical, was closely related to smoking behaviour. Girls at the top of the social pecking order who projected an image of high self-esteem were identified as most likely to smoke, while only a small minority of girls fitted the stereotype of the young female smoker who has poor social skills and low self-esteem. Boys of high social status were less vulnerable, since sport and a desire to be fit to some extent protected them. Our findings raise fundamental questions about the meaning of self-esteem in relation to smoking uptake, arguing instead for an exploration of the term "self-worth". They suggest the need for health education programmes which are sensitive both to gender and to peer group structures.

Women and smoking

Smoking kills over half a million women each year and is the most important preventable cause of female premature death in several developed countries. However, in many countries, cigarette smoking still tends to be regarded as a mainly male problem. This paper explores the reasons why more attention needs to be paid to issues around smoking and women, even in countries which currently have low levels of female cigarette smoking. The article includes an overview of current patterns and trends of smoking among women, and the factors which influence smoking uptake and cessation in women compared to men. The experience of countries with the longest history of widespread female smoking is used to identify some of the key challenges facing developed and developing countries. Tobacco companies have identified women as a key target group, therefore particular attention is given to the ways in which they have attempted to reach women through advertising and other marketing strategies. It is concluded that in order to halt and ultimately reverse the tobacco epidemic among women, tobacco control policies need to encompass both gender-specific and gender-sensitive approaches. Examples are given of the types of action that are needed in relation to research, public policy and legislation, and education.

Is a telephone helpline of value to the workplace smoker?

This paper reports the findings of the evaluation of a national smokers' helpline which was set up by British Telecom (BT) for its employees. The helpline formed part of a new comprehensive smoking policy for all BT staff. Over 1000 employees, more than 3.0% of all smokers, phoned the helpline during the first three months of its operation. Two-thirds of callers tried to quit smoking after calling the helpline, and a quarter were still successful three months later. One in six callers reduced the number of cigarettes that they smoked on working days. While the helpline and other cessation support services were evaluated positively by callers, it appears that helplines only appeal to a small minority of smokers. However, they do seem to be an effective mechanism for a nationwide company to identify those smokers who want support, and a useful means of centralizing the administration of support services. They are potentially a cost-effective option for larger employers.

Assessing personal process learning in a health promotion module for medical students

This paper describes the development and evaluation of an assessment method for personal process learning in a student-centred health promotion module. Personal process learning refers to students' awareness and understanding of their learning about personal values and attitudes, their skills for planning change, and their communication skills. The assessment forms part of the professional examination in public health. The paper documents and critically reviews the assessment method in the light of student feedback. The problem of student acceptability is highlighted and we describe the adjustments that have been made in response to this and how they have been received. It is concluded that medical students are open to innovative forms of assessment as long as they perceive them to be valid, fair and equitable.

Annual recertification: fun? Wow!

Learning is critical to fostering a knowledge base required for maintaining currency and furthering professional development. In the ever-changing field of nephrology, most skills practised in nursing are considered to be sanctioned medical acts or added nursing skills. Therefore, annual recertification of the skills designated as sanctioned medical acts is an expectation of the College of Nurses of Ontario. The Wellesley Hospital policy indicates one time only or annual approval of the added nursing skills. The article will discuss the use of games as a creative, non-threatening educational tool in the recertification/re-approval process currently in place at The Wellesley Hospital, renal programs. In the past two years, several games or alternative teaching strategies have been utilized to assist the staff in preparing for recertification. This paper will examine the advantages and disadvantages of utilizing alternative teaching formats. Commentary regarding the response of staff nurses, nursing management and education will be highlighted.

A comparison of the consistency of self-reported behavioural change within a study sample--postal versus home interviews

Much health promotion research is directed towards increasing our understanding of the process of health-related behavioural change. However, little is known about the validity of self-reported changes in behaviour. This study aimed to assess the validity of self-reported changes in five behaviours--diet, cigarette smoking, alcohol consumption, weight control and physical activity--by comparing reports obtained from the same people through postal questionnaires and face-to-face interviews. It was found that overall there was a consistency between self-reports with interviewers confirming that in most cases change had taken place. However, in a large number of cases changes were reported that had occurred before the period specified in the questionnaire. The nature of the change, whether discrete or incremental, as well as the behaviour in question, were found to be related to the accuracy of self-reporting. The possible reasons for the observed discrepancies are discussed.

Hospital smoking policies: examples of good practice?

Health services should be taking a lead in implementing smoking policies which promote smoke-free environments for patients, visitors and staff, and ensure that patients and staff are provided with information and advice about smoking and how to give it up. Yet the evidence suggests that the implementation of such policies is patchy, particularly in countries where there are high smoking rates amongst health workers, including doctors. This article discusses, in the light of experience from Spain and the UK, some of the factors which are important in determining the success of such programmes. It is argued that such programmes will be of benefit to the future health of both patients and staff.

Cigarette advertising policy and coverage of smoking and health in British women's magazines

A survey of cigarette advertising and coverage of health aspects of smoking in 86 British magazines with a large female readership was done in 1989. The findings were compared with the results of a 1985 survey which had led to the introduction of new voluntary restrictions in 1986 on cigarette advertising in magazines. Although there was a decrease in the proportion of magazines accepting cigarette advertising (64% to 42%), the new restrictions failed to cover the most popular magazines, so that an estimated collective readership of 7 million women aged 15-24 years were still exposed to cigarette advertising. Revenue from cigarette advertising by women's magazines increased by 10% in real terms between 1985 and 1988. There was a small decrease in the coverage given to health aspects of smoking; a third of magazines were willing to use pictures of people smoking in their editorial pages. The findings show that the voluntary restrictions introduced in the UK in 1986 have had a small effect on cigarette advertising and have failed to achieve their aim of protecting young women.