An action-oriented public health framework to reduce financial strain and promote financial wellbeing in high-income countries

BACKGROUND

Perceived financial security impacts physical, mental, and social health and overall wellbeing at community and population levels. Public health action on this dynamic is even more critical now that the COVID-19 pandemic has exacerbated financial strain and reduced financial wellbeing. Yet, public health literature on this topic is limited. Initiatives targeting financial strain and financial wellbeing and their deterministic effects on equity in health and living conditions are missing. Our research-practice collaborative project addresses this gap in knowledge and intervention through an action-oriented public health framework for initiatives targeting financial strain and wellbeing.

METHODS

The Framework was developed using a multi-step methodology that involved review of theoretical and empirical evidence alongside input from a panel of experts from Australia and Canada. In an integrated knowledge translation approach, academics (n = 14) and a diverse group of experts from government and non-profit sectors (n = 22) were engaged throughout the project via workshops, one-on-one dialogues, and questionnaires.

RESULTS

The validated Framework provides organizations and governments with guidance for the design, implementation, and assessment of diverse financial wellbeing- and financial strain-related initiatives. It presents 17 priority actionable areas (i.e., entry points for action) likely to have long-lasting, positive effects on people's financial circumstances, contributing to improved financial wellbeing and health. The 17 entry points relate to five domains: Government (All Levels), Organizational & Political Culture, Socioeconomic & Political Context, Social & Cultural Circumstances, and Life Circumstances.

CONCLUSIONS

The Framework reveals the intersectionality of root causes and consequences of financial strain and poor financial wellbeing, while also reinforcing the need for tailored actions to promote socioeconomic and health equity for all people. The dynamic, systemic interplay of the entry points illustrated in the Framework suggest opportunities for multi-sectoral, collaborative action across government and organizations towards systems change and the prevention of unintended negative impacts of initiatives.

A Policy-Ready Public Health Guidebook of Strategies and Indicators to Promote Financial Well-Being and Address Financial Strain in Response to COVID-19

INTRODUCTION

The COVID-19 pandemic has adversely affected the financial well-being of populations globally, escalating concerns about links with health care and overall well-being. Governments and organizations need to act quickly to protect population health relative to exacerbated financial strain. However, limited practice- and policy-relevant resources are available to guide action, particularly from a public health perspective, that is, targeting equity, social determinants of health, and health-in-all policies. Our study aimed to create a public health guidebook of strategies and indicators for multisectoral action on financial well-being and financial strain by decision makers in high-income contexts.

METHODS

We used a multimethod approach to create the guidebook. We conducted a targeted review of existing theoretical and conceptual work on financial well-being and strain. By using rapid review methodology informed by principles of realist review, we collected data from academic and practice-based sources evaluating financial well-being or financial strain initiatives. We performed a critical review of these sources. We engaged our research-practice team and government and nongovernment partners and participants in Canada and Australia for guidance to strengthen the tool for policy and practice.

RESULTS

The guidebook presents 62 targets, 140 evidence-informed strategies, and a sample of process and outcome indicators.

CONCLUSION

The guidebook supports action on the root causes of poor financial well-being and financial strain. It addresses a gap in the academic literature around relevant public health strategies to promote financial well-being and reduce financial strain. Community organizations, nonprofit organizations, and governments in high-income countries can use the guidebook to direct initiative design, implementation, and assessment.

Animal Protection, Law Enforcement, and Occupational Health: Qualitative Action Research Highlights the Urgency of Relational Coordination in a Medico-Legal Borderland

Simple Summary

In this article, we report on action research in the Canadian province of Alberta, based on forging alliances with officers who enforce federal, provincial, and municipal legislation involving animals. Some of these officers worked in rural areas, and others worked in urban areas. Some mainly enforced Alberta’s Animal Protection Act, while a few specialized in enforcing Canada’s Criminal Code. For the most part, however, participating officers had a mandate to enforce animal-related local bylaws. Such ordinances or rulebooks exist because Alberta’s Municipal Government Act allows local councils to enact legislation regarding domestic and wild animals, particularly as regards people’s health, property, safety, and welfare. Many professionals refer to policies such as these, which are deeply rooted in the western legal tradition, such as “animal control.” Our findings illuminate how animal-control policies and personnel can help to protect domesticated animals, not just people. Even so, our research highlights that animal-control policies as well as animal-protection policies routinely fail to protect officers who enforce legislation involving animals. Furthermore, whenever officers who enforce legislation involving animals work in unsafe conditions, this endangers human as well as non-human lives.

Abstract

Across Canada and internationally, laws exist to protect animals and to stop them from becoming public nuisances and threats. The work of officers who enforce local bylaws protects both domestic animals and humans. Despite the importance of this work, research in this area is emergent, but growing. We conducted research with officers mandated to enforce legislation involving animals, with a focus on local bylaw enforcement in the province of Alberta, Canada, which includes the city of Calgary. Some experts regard Calgary as a “model city” for inter-agency collaboration. Based on partnerships with front-line officers, managers, and professional associations in a qualitative multiple-case study, this action-research project evolved towards advocacy for occupational health and safety. Participating officers spoke about the societal benefits of their work with pride, and they presented multiple examples to illustrate how local bylaw enforcement contributes to public safety and community wellbeing. Alarmingly, however, these officers consistently reported resource inadequacies, communication and information gaps, and a culture of normalized disrespect. These findings connect to the concept of “medico-legal borderlands,” which became central to this study. As this project unfolded, we seized upon opportunities to improve the officers’ working conditions, including the potential of relational coordination to promote the best practices.

Impact of health system engagement on the health and well-being of people who use drugs: a realist review protocol

BACKGROUND

Although community-level benefits of health system engagement (i.e., health service planning, delivery, and quality improvement, engaged research and evaluation, and collaborative advocacy) are well established, individual-level impacts on the health and well-being of community members are less explored, in particular for people who use or have used illegal drugs (PWUD). Capacity building, personal growth, reduced/safer drug use, and other positive outcomes may or may not be experienced by PWUD involved in engagement activities. Indeed, PWUD may also encounter stigma and harm when interacting with healthcare and academic structures. Our objective is to uncover why, how, and under what circumstances positive and negative health outcomes occur during health system engagement by PWUD.

METHODS

We propose a realist review approach due to its explanatory lens. Through preliminary exploration of literature, lived experience input, and consideration of formal theories, an explanatory model was drafted. The model describes contexts, mechanisms, and health outcomes (e.g., mental health, stable/safer drug use) involved in health system engagement. The explanatory model will be tested against the literature and iteratively refined against formal theories. A participatory lens will also be used, wherein PWUD with lived experience of health system engagement will contribute throughout all stages of the review.

DISCUSSION

We believe this is the first realist review to explore the contextual factors and underlying mechanisms of health outcomes for PWUD who participate in health system engagement. A thorough understanding of the relevant literature and theoretical underpinnings of this process will offer insights and recommendations to improve the engagement processes of PWUD.

Circulating secretoneurin concentrations are increased in patients with acute coronary syndrome and provide prognostic information

Background

Secretoneurin (SN) is associated with both myocardial ischemia and cardiomyocyte Ca2+ handling, and circulating SN levels provide incremental prognostic information to established risk indices in patients with acute heart failure, acute respiratory failure, and after cardiac arrest.

Purpose

To determine whether SN concentrations are increased in patients with acute coronary syndrome (ACS), and assess the prognostic value of SN among patients with suspected ACS.

Methods

We included 402 patients hospitalized with chest pain at a teaching hospital and adjudicated all hospitalizations as ACS or non-ACS by two physicians working independently. Blood samples were drawn within 24 h from hospital admission and SN was measured by a novel ELISA assay. Patients were followed for mean 6.2 years and mortality was obtained from the Norwegian Cause of Death Registry.

Results

SN concentrations were higher in patients with ACS (n=161 [40%]) compared to patients with chest pain without ACS (n=241 [60%]): median 32.8 (IQR 27.5–42.8) vs. 28 (24.5–34.0) pmol/L, p<0.001. The C-statistics of SN was 0.66 (95% CI: 0.61–0.71) to separate chest pain patients with ACS from chest pain patients without ACS compared to 0.82 (0.78–0.86) for high-sensitivity cardiac troponin T (hs-cTnT). Patients with ECG changes reflective of acute myocardial ischemia had higher SN concentrations (p=0.005). Sixty-five (16%) patients died during follow-up. Stratifying patients according to SN concentrations separated patients with a poor and favorable prognosis, and patients with SN in the top quartile had 4-fold higher risk of mortality compared to the patients with low SN concentrations (Figure). Higher SN concentrations were also associated with increased risk of mortality in Cox regression models, including in models that adjusted for age, sex, blood pressure, previous myocardial infarction, atrial fibrillation, and heart failure: hazard ratio 1.71 (1.03–2.84), p=0.038. The C-statistics of SN to separate patients with poor prognosis from favorable prognosis was 0.72 (0.65–0.79) and adding SN on top of hs-cTnT improved prognostication as assessed by the integrated discrimination index: 0.05±0.014, p<0.001.

Conclusions

SN concentrations are increased in patients with ACS and provide prognostic information in patients with chest pain.

Figure 1

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Akershus Unviersity Hospital, CardiNor AS

Searching for the Impact of Participation in Health and Health Research: Challenges and Methods

Internationally, the interest in involving patients and the public in designing and delivering health interventions and researching their effectiveness is increasing. Several systematic reviews of participation in health research have recently been completed, which note a number of challenges in documenting the impact of participation. Challenges include working across stakeholders with different understandings of participation and levels of experience in reviewing; comparing heterogeneous populations and contexts; configuring findings from often thin descriptions of participation in academic papers; and dealing with different definitions of impact. This paper aims to advance methods for systematically reviewing the impact of participation in health research, drawing on recent systematic review guidance. Practical examples for dealing with issues at each stage of a review are provided based on recent experience. Recommendations for improving primary research on participation in health are offered and key points to consider during the review are summarised.

Hegemony or health promotion? Prospects for reviving England's lost discipline

Since 1997, health promotion has been steadily disappearing from public health in England. This is not only true of the phrase, but also of the concepts and the discipline it represents. Given the undoubted increase in health-promoting policies and programmes during this period, we consider whether this situation could represent a welcome mainstreaming of health promotion. However, on the basis of a detailed historical and contemporary review of health promotion and public health theory and practice, we conclude that this is not in fact the case. Rather, health promotion in England should be seen as the subject of a hegemonic absorption by an increasingly individualistic public health discourse. The currently increasing focus on well-being could, however, represent an opportunity for health promotion in England to be revived and reinvented.

The use of potential years of life lost for monitoring premature mortality from chronic diseases: Canadian perspectives

Given that chronic diseases account for 88% of all deaths in Canada, robust surveillance and monitoring systems are essential for supporting implementation of health promotion and chronic disease prevention policies. Canada has a long tradition of monitoring premature mortality expressed as potential years of life lost (PYLL), dating back to the seminal work by Romeder and McWhinnie in the late 1970s, who pioneered the use of PYLL as a tool in health planning and decision-making. The utility of PYLL for monitoring progress was expanded in the 1990s through the national comparable Health Indicators Initiative, following which PYLL has been monitored for several decades nationally, provincially, regionally and locally as part of health systems' performance measurement. Yet the potential for using PYLL in health promotion and chronic disease prevention has not been maximized. Linking PYLL with public health programs and initiatives aimed at health promotion and chronic disease prevention, introduced starting in the 1990s, would inform whether these efforts are making progress in addressing the burden of premature mortality from chronic diseases. Promoting the use of PYLL due to chronic diseases would contribute toward providing a more complete picture of chronic diseases in Canada.

How stakeholder participation can contribute to systematic reviews of complex interventions

Although patient and public involvement in research is a requirement for research funding in many countries, the knowledge base for how to effectively involve people—and evidence of the effectiveness of involvement—is weak. This article describes how methods used in participatory health research were used to involve patients, clients, providers and community health workers across all stages of a realist review. Sustained involvement enabled better identification of the components of the complex intervention of community-based peer support. It also challenged assumptions of how peer support is constructed, leading the review team to question whether the process of designing and implementing interventions has more influence on effectiveness than previously recognised in empirical studies. We conclude with a discussion on when sustained involvement should be used, and the challenges of incorporating it into the traditional researcher-led approach to systematic reviews.

Can community-based peer support promote health literacy and reduce inequalities? A realist review

Background

Community-based peer support (CBPS) has been proposed as a potentially promising approach to improve health literacy (HL) and reduce health inequalities. Peer support, however, is described as a public health intervention in search of a theory, and as yet there are no systematic reviews exploring why or how peer support works to improve HL.

Objective

To undertake a participatory realist synthesis to develop a better understanding of the potential for CBPS to promote better HL and reduce health inequalities.

Data sources

Qualitative evidence syntheses, conceptual reviews and primary studies evaluating peer-support programmes; related studies that informed theoretical or contextual elements of the studies of interest were included. We conducted searches covering 1975 to October 2011 across Scopus, Global Health (including MEDLINE), ProQuest Dissertations & Theses database (PQDT) [including the Education Resources Information Center (ERIC) and Social Work Abstracts], The King’s Fund Database and Web of Knowledge, and the Institute of Development Studies supplementary strategies were used for the identification of grey literature. We developed a new approach to searching called ‘cluster searching’, which uses a variety of search techniques to identify papers or other research outputs that relate to a single study.

Study eligibility criteria

Studies written in English describing CBPS research/evaluation, and related papers describing theory, were included.

Study appraisal and synthesis methods

Studies were selected on the basis of relevance in the first instance. We first analysed within-programme articulation of theory and appraised for coherence. Cross-programme analysis was used to configure relationships among context, mechanisms and outcomes. Patterns were then identified and compared with theories relevant to HL and health inequalities to produce a middle-range theory.

Results

The synthesis indicated that organisations, researchers and health professionals that adopt an authoritarian design for peer-support programmes risk limiting the ability of peer supporters (PSs) to exercise autonomy and use their experiential knowledge to deliver culturally tailored support. Conversely, when organisations take a negotiated approach to codesigning programmes, PSs are enabled to establish meaningful relationships with people in socially vulnerable groups. CBPS is facilitated when organisations prioritise the importance of assessing community needs; investigate root causes of poor health and well-being; allow adequate time for development of relationships and connections; value experiential cultural knowledge; and share power and control during all stages of design and implementation. The theory now needs to be empirically tested via further primary research.

Limitations

Analysis and synthesis were challenged by a lack of explicit links between peer support for marginalised groups and health inequalities; explicitly stated programme theory; inconsistent reporting of context and mechanism; poor reporting of intermediate process outcomes; and the use of theories aimed at individual-level behaviour change for community-based interventions.

Conclusions

Peer-support programmes have the potential to improve HL and reduce health inequalities but potential is dependent upon the surrounding equity context. More explicit empirical research is needed, which establishes clearer links between peer-supported HL and health inequalities.

Study registration

This study is registered as PROSPERO CRD42012002297.

Funding

The National Institute for Health Research Public Health Research programme.

Towards a methodology for cluster searching to provide conceptual and contextual "richness" for systematic reviews of complex interventions: case study (CLUSTER)

Background

Systematic review methodologies can be harnessed to help researchers to understand and explain how complex interventions may work. Typically, when reviewing complex interventions, a review team will seek to understand the theories that underpin an intervention and the specific context for that intervention. A single published report from a research project does not typically contain this required level of detail. A review team may find it more useful to examine a “study cluster”; a group of related papers that explore and explain various features of a single project and thus supply necessary detail relating to theory and/or context.

We sought to conduct a preliminary investigation, from a single case study review, of techniques required to identify a cluster of related research reports, to document the yield from such methods, and to outline a systematic methodology for cluster searching.

Methods

In a systematic review of community engagement we identified a relevant project – the Gay Men’s Task Force. From a single “key pearl citation” we conducted a series of related searches to find contextually or theoretically proximate documents. We followed up Citations, traced Lead authors, identified Unpublished materials, searched Google Scholar, tracked Theories, undertook ancestry searching for Early examples and followed up Related projects (embodied in the CLUSTER mnemonic).

Results

Our structured, formalised procedure for cluster searching identified useful reports that are not typically identified from topic-based searches on bibliographic databases. Items previously rejected by an initial sift were subsequently found to inform our understanding of underpinning theory (for example Diffusion of Innovations Theory), context or both. Relevant material included book chapters, a Web-based process evaluation, and peer reviewed reports of projects sharing a common ancestry. We used these reports to understand the context for the intervention and to explore explanations for its relative lack of success. Additional data helped us to challenge simplistic assumptions on the homogeneity of the target population.

Conclusions

A single case study suggests the potential utility of cluster searching, particularly for reviews that depend on an understanding of context, e.g. realist synthesis. The methodology is transparent, explicit and reproducible. There is no reason to believe that cluster searching is not generalizable to other review topics. Further research should examine the contribution of the methodology beyond improved yield, to the final synthesis and interpretation, possibly by utilizing qualitative sensitivity analysis.

The Roy Castle Fag Ends Stop Smoking Service: A Successful Client-Led Approach to Smoking Cessation

The Roy Castle Fag Ends Community Stop Smoking Service (RCFE) is commissioned by three primary care trusts (PCTs) to provide the adult smoking-cessation service across Liverpool. The service is not theoretically driven but there are several principles governing RCFE, which maintain the client-led, person-centred philosophy. Unique aspects are that the service is provided by trained lay advisors with a nonmedical background and there is no waiting list — clients can self-refer by calling a helpline or walking into a meeting. At RCFE, clients control their own quit attempt as well as self-regulating attendance at meetings and discharge from the service. Relapsed clients are also welcomed back without fear of criticism or the need for an appointment. Possible reasons for the success of RCFE include the client-led methodology, the community approach that removes doctor–patient barriers that may exist, and the nature of the group meetings, which allows interaction between clients who are at different stages of the quit process. Introducing some of the RCFE principles into other stop-smoking services may help to increase the overall smoking-cessation rate in England.

Telling stories from everyday practice, an opportunity to see a bigger picture: a participatory action research project about developing discharge planning

In spite of laws, rules and routines, findings from Swedish as well as international research show that discharge planning is not a simple matter. There is considerable knowledge about discharge planning, but the quality of the actual process in practice remains poor. With this in mind, a research and developmental health and social care network decided to use participation action research to explore the discharge planning situation in order to generate new ideas for development. This paper reports on the research process and the findings about our enhanced understanding about the discharge planning situation. Story dialogue method was used. The method is based on stories from everyday practice. The stories are used as 'triggers' to ask probing questions in a dialog and structured form. Local theory is developed to help the participants to find solutions for action in the practice. Our findings were that the discharge planning situation could be seen as a system including three interconnected areas: patient participation, practitioners' competence and organizational support. To reach good quality in discharge planning, all these three issues need to be developed, but not only as routines and forms. Rather, when developing a discharge planning situation, a system where relational aspects such as confidence and continuity are essential and thus needs to be considered. To achieve a change, the core problem needs to be clarified. When the issue is complex, the solution needs to consider the bigger picture and not just the parts. Telling stories from everyday practice, and to systematically reflect and analyse those in interprofessional groups can create opportunities for enhanced understanding, as well as be a vehicle for future change of practice.

Methodological issues in emergent evaluations of health programs: lessons from Iberoamerica

There has been growing interest in nonmainstream approaches to assessing health programs, but methodological strategies have not been a concern. In this article, we review methodological strategies used in emergent evaluations of health policies and programs in Iberoamerica, focusing on participatory, qualitative, critical, hermeneutical, bottom-up, collaborative, and transdisciplinary approaches. A literature search was performed combining strategies: database review, consultation of bibliography, expert interviews, and search engines. The review took place from 2003 to 2006. Research published in the past two decades was included. Nearly 70 articles were found on emergent research and evaluation of health programs in the region. Participatory and qualitative approaches were the most used. Theoretical issues are more emphasized than are methodological ones. Data gathering also was more explored than were design, participant selection, or analysis. The frequently used methodological strategies contradict some basic assumptions of the emergent evaluative research, such as its participatory and collaborative nature.

From rhetoric to reality: A systemic approach to understanding the constraints faced by Health For All initiatives in England

The increased appreciation of the effects socio-ecological factors have on health, witnessed over the last few decades, has given rise to many international, national, and local Health For All (HFA) initiatives tasked with addressing them. However, such initiatives have had to operate within environments which were not specifically designed for them or for the new social (rather than medical) perspective on health they were based upon. As a result, they have been facing significant barriers and constraints to fulfilling their mission. This paper explores the constraints which are imposed on such initiatives by the various environments within which they are nested. Drawing upon our experience in evaluating European Healthy City (HC) projects and English Health Action Zones (HAZs), we develop a dynamic conceptual model which shows how the national, governmental policy, interorganisational, organisational, and initiative environments relate with each other and their cumulative effects on initiatives. We argue that this model, and the principles on which it is based, can be used constructively to identify constraints facing HFA-type initiatives in many countries. We use our case study of English HCs and HAZs to illustrate the applicability of the model in a particular national context. We, first, interpret the model to reflect differences and similarities between their respective environments and trace the sources of the different constraints they encountered. We, then, show how an alternative structural configuration could enable some of these constraints to be eliminated. We argue that what is needed for HFA initiatives to be able to fulfill their brief in full is for governments to rethink existing organisational structures and update them to match the evolution of ideas on health which have emerged over the last decades.

From rhetoric to reality: barriers faced by Health For All initiatives

The last two decades have witnessed an upsurge in the development and implementation of 'Health For All-type' initiatives in many parts of the world. However, despite the popularity of the approach, barriers and constraints to the fulfillment of their remit still persist, making it difficult for them to achieve the potential originally envisaged. Drawing upon considerable empirical work while evaluating the European Healthy City projects and English Health Action Zones, this paper explores the differences between barriers and constraints and then focuses on barriers as they manifest themselves in England. It distinguishes between cultural barriers, stemming from different philosophical, organisational, and professional/experiential cultures, and political barriers, stemming from both party political and realpolitik concerns. It discusses how these barriers often operate together, compounding their individual impacts, with detrimental effects for Health For All initiatives. Consequently, while the prevailing rhetoric appears to promote an alternative, and more appropriate, vision of how health can be maintained and enhanced, these barriers effectively function to sustain the hegemony of the status quo which was, and is, based on a different and outdated vision. We argue that acknowledging the continuous persistence of these barriers is an essential first step towards turning the prevailing health-related rhetoric into reality.

'Stop it, it's bad for you and me': experiences of and views on passive smoking among primary-school children in Liverpool

This article looks at how children between the ages of 4 and 8 years report they feel when they are exposed to passive smoking and how they react in these situations. Data were collected annually from a cohort of 250 primary school children, which was tracked from their Reception Classes to Year 3 across six Liverpool schools. Quantitative and qualitative methods were employed--including a survey, the Draw and Write investigative technique and semi-structured interviews. Findings showed that children had some understanding of the health problems that passive smoking posed to both themselves and the smoker. Between the ages of 4 and 7 the majority of children held negative feelings about being exposed to smoke, but at the age of 8 there is a clear decline in negative expressions. Most of the children were prepared verbally to confront a smoker, usually a parent, in order to get them to stop, but rarely took direct action and left the room themselves. Results suggest that children would be receptive to information on the dangers of smoking during the early years of primary school, while the dialogue between children and their parents suggests that the latter have a key role to play in strategies to tackle passive smoking in the home.

Some lessons from Swedish midwives' experiences of approaching women smokers in antenatal care

OBJECTIVE

to describe the qualitatively different ways in which midwives make sense of how to approach women smokers.

DESIGN, SETTING AND PARTICIPANTS

a more person-centred national project 'Smoke-free pregnancy' has been in progress in Sweden since 1992. Using a phenomenographic approach, 24 midwives who have been regularly working in antenatal care were interviewed about addressing smoking during pregnancy.

FINDINGS

four different story types of how the midwives made sense of their experiences in addressing smoking in pregnancy were identified: 'avoiding', 'informing', 'friend-making', 'co-operating'.

KEY CONCLUSION

the midwives' story types about how they approached women who smoke illustrated the difficulties of changing from being an expert who gives information and advice to being an expert on how to enable a woman in finding out why she smoked and how to stop smoking.

IMPLICATIONS FOR PRACTICE

health education about smoking that is built on co-operation and dialogue was seen by the midwives as a productive way of working. The starting point should be the lay perspective of a woman, which means that her thoughts about smoking cessation are given the space to grow while she talks.

Making sense of the challenge of smoking cessation during pregnancy: a phenomenographic approach

In general, most women are familiar with the need to stop smoking when they are pregnant. In spite of this, many women find it difficult to stop. Using a phenomenographic approach, this study explored Swedish pregnant and post-pregnant women's ways of making sense of smoking during pregnancy. A total of 17 women who either smoked throughout pregnancy or stopped smoking during pregnancy were interviewed. Five different story types of how they are making sense of smoking during pregnancy were identified: smoking can be justified; will stop later; my smoking might hurt the baby; smoking is just given up; smoking must be taken charge of. Based on the study it is argued that the approach used in health education in relation to smoking cessation in antenatal care needs to move from information transfer and advice-giving to the creation of a dialogue. The starting point should be the woman's knowledge, concerns, rationalizations and prejudices. A model is suggested in which a woman may move in a space on three axes depending on life encounters, dialogue and reflections on meaning. The goal in health education would be to encourage movement along three axes: 'increase of self-efficacy towards control', 'increase awareness by reflection on meaning of the smoking issue' and 'avoidance of defense of the smoking behavior'.

Geographically-based approaches to the integration of health promotion into health systems: a comparative study of two Health Action zones in the UK

Health Action Zones (HAZs) were introduced in the UK in the late 1990s as a whole system approach to public health and health care. Resources were targeted in historically deprived subregional units of England. Based on process evaluations undertaken in their fourth year of operation, the approaches taken by two HAZs were compared. Each had different histories of intersectoral cooperation and strategic approaches to integration. Both operated in a rapidly changing policy and organizational environment. This undermined attempts to sustain a consistent vision and eventually led to the demise of HAZs as subregional units. The approaches chosen by these two HAZs to integrate health promotion into health systems cannot be divorced from the political, historical and geographical contexts in which they were initiated. What the experiences of the two HAZs demonstrate is that while subregions and localities can potentially benefit from a whole systems perspective, there are deep-seated structural problems that constrain progress. Their experience demonstrates that context is of key importance in understanding the outcomes of any intervention aimed at promoting health.

Why do primary school children smoke? A longitudinal analysis of predictors of smoking uptake during pre-adolescence

The objectives of this longitudinal study were to determine the prevalence of smoking among primary school children in Liverpool, and to identify the predictors of experimentation with cigarettes during pre-adolescence. A cohort of children (n = 270) completed questionnaires that elicited patterns of child smoking behaviour and children's experiences of smoking in their families and communities each year between the ages of 9 and 11 years. Parents also completed questionnaires. Children's first trials with cigarettes and repeated smoking were reported. The independent variables measured were socio-economic status, familial and peer smoking, and intentions to smoke. By age 11, 27% of children had tried smoking, 12% had smoked repeatedly and 3% were smoking regularly. Variables measured at age 9 predicting experimentation with cigarettes by age 11 were male gender 9P = 0.041) paternal smoking (P = 0.001) fraternal smoking (P = 0.017) a best friend who smoked (P = 0.026) and knowing someone with a smoking-related disease (P = 0.006) Intentions to smoke at age 9 did not predict smoking at age 11 (P < 0.001). In univariate analyses, child smoking was also associated with maternal smoking (P = 0.002 at age 11), living in a low-income household (P < 0.001 at age 10) and living in a deprived area ( P = 0.025 at age 11). Early smoking presents a considerable challenge to health promoters, not least because it is socially patterned. The interventions required must tackle the structural and social pressures that shape smoking behaviour during childhood.

Using care pathways in pressure area management: a pilot study

Care pathways are a method of managing, delivering and documenting care. A pilot study of a care pathway system in pressure area management was conducted in two clinical areas. Results from this pilot study indicate that the pathway approach to pressure area management is both useful and valid as a means to enhance clinical decision-making and to facilitate comprehensive pressure area management and the completeness of care documentation. Implementation of the pathway requires a facilitator to provide support and education and to monitor and maintain the change process.

Primary schoolchildrens' perceptions of smoking: implications for health education

This paper suggests that there is a need, as early as Reception, to implement smoking intervention programmes in the local school curriculum. Findings from a cross-sectional study have shown that primary schoolchildren (4-8 years old) possess negative attitudes and beliefs about smoking, have as yet to establish regular patterns of smoking behaviour, and have a broad understanding of the nature of smoking. Health educators need to capitalize on this negative disposition toward smoking via early intervention; however, to date, there are no smoking-specific health education measures for this age group. The implementation of proactive programmes, before the habit manifests itself, has many supporters but little research has been conducted. This study was devised to fill this significant gap in the literature on smoking. Data was collected on a representative sample of primary schoolchildren in the city of Liverpool. A triangular methodology was adopted consisting of questionnaires (N = 1701), the Draw and Write investigative technique (N = 976), and semi-structured interviews (N = 50). The results highlight the need to implement smoking intervention programmes from Reception onward, the importance of developing a model that is more than just knowledge based and the necessity of involving the family in any school-based health education strategies.

Does the sedation resulting from sleep deprivation and lorazepam cause similar cognitive deficits?

It is notoriously difficult to assess the contribution of the sedative effects of benzodiazepines to the cognitive impairments that they produce. The purpose of the present experiment was to determine whether a similar pattern of cognitive impairment would be seen in conditions when subjects felt equally sleepy as the result of sleep deprivation. The effects of a sedative dose of lorazepam (2.5 mg) in healthy volunteers was therefore compared with the effects of acute sleep deprivation (a night on-call) in a group of junior doctors and the effects of chronically disturbed sleep due to snoring. Lorazepam, acute sleep deprivation, and chronic sleep disturbance all significantly increased subjective sedation. In addition, lorazepam significantly impaired performance in two tests of psychomotor speed and caused significant anterograde amnesia. Semantic and short-term memory were not impaired by lorazepam, nor was there any impairment in executive function. The only deficit found following acute sleep deprivation was in a test of semantic memory, generating examples from a difficult category. The only significant deficit in the group suffering from chronically disturbed sleep, compared with age-matched controls, was in executive function, and there was a nearly significant impairment in sustained attention. These results suggest that, despite the common factor of increased subjective sedation, the profile of cognitive impairment in the two sleep deprivation groups are neither similar to each other nor to that seen following an acute dose of lorazepam.