[Aftermath of ban on Hungarian medical doctors' informal payment]. / Hálapénz után a magyar egészségügyben.

Since 2020, Hungary's penalty law has banned any undue advantage or its promise for medical services. Parallel, the Health Care Act in force was changed concerning the legally acceptable allowances for medical care. Hungary's medical community and the patients received these changes as ending of the perverse informal payment system parasitizing the public financing. Informal payment disappeared indeed, but it will be hard to get rid of its ruins left behind. For creating transparency, first the health care workers' and general practitioners' quasi informal payment and finally the specialists' so-called parallel net-income (paid by patients' para-solvency) - which was an illegal fee for pretended private practice in the public health care - must be cleared. This pretence was eradicated by clear separation of private and public services. The key issue of any further changes is rearranging the in- and outpatient secondary care run either/or as integrated, separated or partially mixed systems. Determined by ownership, financial and professional environment, the only model will survive in the new era which is based on economic sector neutrality, complies well with the aims of health policy and interests of medical doctors and their patients. Orv Hetil. 2023; 164(14): 523-532.

On the relation of the frame-related operators of fusion frame systems.

Frames have been investigated frequently over the last few decades due to their valuable properties, which are desirable for various applications as well as interesting for theory. Some applications additionally require distributed processing techniques, which naturally leads to the concept of fusion frames and fusion frame systems. The latter consists of a system of subspaces, equipped with local frames on each of them, and a global frame. In this paper, we investigate the relations of the associated frame-related operators on all those three levels. For that we provide a detailed investigation on bounded block diagonal operators between Hilbert direct sums. We give the relation of the frame-related operators of the fusion frame and the corresponding frame systems in terms of operator identities. By applying these identities we prove further properties of fusion frame systems.

Time trade-off health state utility values for depression: a systematic review and meta-analysis.

PURPOSE: This study aims to systematically review the literature on health utility in depression generated by time trade-off (TTO) method and to compare health state vignettes. METHODS: Systematic literature search was conducted following PRISMA guideline in 2020 November (updated in 2022 March) in Pubmed, Web of Science, PsycInfo, and Cochrane Database of Systematic Reviews. Random effect meta-analysis was conducted to pool vignette-based utility values of mild, moderate, and severe depression and to compare the preferences of depressed and nondepressed population. RESULTS: Overall, 264 records were found, 143 screened by title and abstract after removing duplicates, 18 assessed full text, and 14 original publications included. Majority of the studies (n = 9) used conventional TTO method, and most of the studies (n = 8) applied 10-year timeframe. Eight studies evaluated self-experienced health (own-current depression). Six studies assessed vignette-based health states of remitted, mild, moderate, and severe depression, half of them applied McSad measure based health description. Altogether, 61 different utility values have been cataloged, mean utility of self-experienced depression states (n = 33) ranged between 0.89 (current-own depression) and 0.24 (worst experienced depression). Pooled utility estimates for vignette-based mild, moderate, and severe depression was 0.75, 0.66 and 0.50, respectively. Meta-regression showed that severe depression (ß = -0.16) and depressed sample populations (ß = -0.13) significantly decrease vignette-based utility scores. CONCLUSION: Our review revealed extent heterogeneity both in TTO methodology and health state vignette development. Patient's perception of depression health states was worse than healthy respondents.

Parallel exploratory and confirmatory factor analysis of the Hungarian Fear of COVID-19 Scale in a large general population sample: a psychometric and dimensionality evaluation.

BACKGROUND: This study aims to confirm validity and reliability of the Hungarian version of Fear of COVID-19 Scale (FCV-19S) and evaluate its dimensional structure. METHODS: Cross-sectional survey was carried out in 2021 among Hungarian general population. In addition to classical test theory methods, construct dimensionality of FCV-19S was assessed using EFA with principal axis factoring method and CFA with diagonally-weighted least squares estimation. Fear score was compared in age, gender, educational level, vaccination and infection subgroups. RESULTS: Significant differences in FCV-19S mean scores were observed between three subgroups (age, gender, vaccination). Items showed good internal consistency (Cronbach α = 0.88). EFA identified two latent factors (eig = 4.2 and 1.02), though parallel analysis supports the one-factor model. The two-dimensional structure was confirmed by CFA, items 3,4,6,7 correlated with Factor 1 (physiological fear), items 1,2,5 with Factor 2 (emotional fear). CONCLUSION: The Hungarian version of FCV-19S seems valid and reliable. The EFA identified two-latent factors (emotional and physiological fear), that was confirmed by CFA. The two-factor structure had better model fit, though its' acceptance is limited.

Capturing the songs of mice with an improved detection and classification method for ultrasonic vocalizations (BootSnap).

House mice communicate through ultrasonic vocalizations (USVs), which are above the range of human hearing (>20 kHz), and several automated methods have been developed for USV detection and classification. Here we evaluate their advantages and disadvantages in a full, systematic comparison, while also presenting a new approach. This study aims to 1) determine the most efficient USV detection tool among the existing methods, and 2) develop a classification model that is more generalizable than existing methods. In both cases, we aim to minimize the user intervention required for processing new data. We compared the performance of four detection methods in an out-of-the-box approach, pretrained DeepSqueak detector, MUPET, USVSEG, and the Automatic Mouse Ultrasound Detector (A-MUD). We also compared these methods to human visual or 'manual' classification (ground truth) after assessing its reliability. A-MUD and USVSEG outperformed the other methods in terms of true positive rates using default and adjusted settings, respectively, and A-MUD outperformed USVSEG when false detection rates were also considered. For automating the classification of USVs, we developed BootSnap for supervised classification, which combines bootstrapping on Gammatone Spectrograms and Convolutional Neural Networks algorithms with Snapshot ensemble learning. It successfully classified calls into 12 types, including a new class of false positives that is useful for detection refinement. BootSnap outperformed the pretrained and retrained state-of-the-art tool, and thus it is more generalizable. BootSnap is freely available for scientific use.

Limited-view binary tomography reconstruction assisted by shape centroid.

In this paper, the binary tomographic reconstruction problem for very limited projection data availability is considered. Being this inverse problem highly ill-posed, we propose a new reconstruction model that uses a shape centroid-based regularization term, i.e., we assume that the center of gravity of the object of interest is known, at least approximately, in advance. Motivation for this regularization is found in the close connection between the projection data and the object centroid, as we will show. Experimental evaluation underpins that reasonable results can be obtained from practically minimal amount of projection data, gathered from just one projection direction.

Impact of the first wave of COVID-19 pandemic on the Hungarian university students' social and health behaviour.

BACKGROUND: The COVID-19 pandemic brought quick, severe and unexpected changes to our everyday life and also changed the traditional education pattern of Semmelweis University in the middle of academic year 2019-2020. We explored adaptive changes in Hungarian students' behaviour and their time-budget in order to determine whether quarantine and/or fear of infection were responsible for these changes. METHODS: A self-administered online questionnaire was distributed to all students in the Hungarian language program (N = 7436) of Semmelweis University. Information was collected on basic demographic data, knowledge and attitude about COVID-19, methods of prevention as well as the students' behaviour before, during and after the first wave of the pandemic. Statistical analyses were processed using the IBM-SPSS 25.0 software package. RESULTS: The overall response rate was 11% (N = 816). Only complete responses were processed (55%, N = 447). Among these responders, 83% did not fear the pandemic. Those who greatly feared COVID-19 infection strictly kept all regulations. The number of non-smokers increased by the end of the first wave. The nutrition of 100 students (21%) became healthier and the lockdown reduced the level of physical activity. CONCLUSION: Social and health-related behaviour of medical students changed basically during the first wave of the pandemic and some changes remained after it in tobacco smoking, nutrition and sleeping habits. Time-budget of students changed significantly during the pandemic and did not return to the baseline values. Results of this study justify future multiple systematic research to analyse and better understand the short- and long-term effects of the current crisis.

Role of new digital technologies and telemedicine in pulmonary rehabilitation : Smart devices in the treatment of chronic respiratory diseases.

BACKGROUND: Asthma and chronic obstructive pulmonary diseases are conditions characterized by a variable progression. Some individuals experience longer asymptomatic periods while others acute worsening periods and/or exacerbations triggered by symptom multiplication factors. Medications are adjusted to the patients' respiratory function, self-assessment of health and emerging certain physical changes. A more effective treatment may be applied by real-time data registered during the patient's everyday life. AIM AND METHODS: Introducing new modern digital technology in pulmonary rehabilitation (PR) to help tracking the patients' medication, thus we systematically reviewed the latest publications on telemedicine and pulmonary telerehabilitation. CONCLUSION: The use of the latest digital technologies in PR is very exciting and offers great opportunities while treating patients affected by specific conditions. On the one hand, adherence to medication can be improved in patients with chronic respiratory diseases by using these new state of the art devices; on the other hand, digital devices will also be able to monitor various physiological parameters of patients during their usual everyday activities. Data can be stored on a smartphone and shared with the provider. Relying on this information, physicians will be able to tailor medications and dosage to the specific needs of individual patients. Telerehabilitation may be a sustainable solution to the growing burden of chronic respiratory disease worldwide. However, PR must keep its cornerstones, such as education and motivations, which are most successful when conducted in person. Many issues remain to be resolved in the future, e.g. cybersecurity while using smart devices since they offer unique opportunities for PR.

Effect of interval training with non-invasive ventilation in severe chronic obstructive pulmonary disease-a prospective cohort study with matched control group.

BACKGROUND: In severe chronic obstructive pulmonary disease (COPD), interval training (IT) can be performed with oxygen support, which provides beneficial effect on metabolic processes, tissue perfusion, and peripheral muscle function. METHODS: A prospective cohort study with matched controls was performed on patients in Budapest at the Department of Pulmonary Rehabilitation of the National Koranyi Institute of Pulmonology between January 1, 2020 and March 1, 2020. After a complex condition assessment, both case and control patients participated in a 3-week long complex pulmonary rehabilitation (PR) program that included individual training, education, nutrition, and psychological counseling. Anthropometric and functional data of patients were recorded at both the beginning and end of the PR program. Our research aimed to assess the effect of non-invasive ventilation (NIV) in patients with severe COPD who underwent IT. RESULTS: A total of 18 [male/female: 10 (55.6%)/8 (44.4%)] patients were enrolled in our study. IT with NIV significantly improved the patients' 6-minute walking distance (6MWD) (m) [216.0 (211.5-233.7) vs. 274.0 (247.5-313.5); P<0.001] and quality of life [COPD Assessment Test (CAT): 29.0 (26.9-32.0) vs. 15.0 (13.5-17.5); P<0.001], [modified Medical Research Council (mMRC): 2.0 (1.5-2.0) vs. 1.0 (1.0-2.0); P=0.009]; in addition, there was a significant increase in inspiratory vital capacity (IVC) (ref%) [65.0 (63.0-69.0) vs. 74.7 (70.5-75.0); P=0.015], in chest kinematics (cm) [3.0 (2.5-4.0) vs. 5.5 (4.0-6.5); P<0.001], work rate (Watt) [25.0 (24.0-27.0) vs. 36.0 (35.0-38.0); P<0.001], volume of oxygen consumption [VO2/kg (mL/kg/min): 8.8 (8.5-9.2) vs. 10.3 (10.2-10.7); P<0.001], and Body-mass index, airflow Obstruction, Dyspnea, and Exercise (BODE) index [5.0 (5.0-6.7) vs. 4.0 (3.0-5.0); P=0.006], while the results of the control group were non-significant [6MWD, maximal inspiratory pressure (MIP), CAT, mMRC, BODE index]. CONCLUSIONS: In severe COPD, IT with NIV is well tolerated during PR, it has a significant beneficial effect on the quality of life, improves exercise capacity and respiratory functions, decreases dynamic hyperinflation and dyspnea.

Health utility measurement by time trade-off method in Hungary / Egészséghasznosság-mérés idoalku módszerrel Magyarországon.

Összefoglaló. Bevezetés: Az idoalku (time trade-off) egy nemzetközileg széles körben alkalmazott életminoség- és egészséghasznosság-mérési módszer. Az idoalkuval mért hasznosságértékek az egészségügyi technológiák költséghatékonysági vizsgálatakor az életminoséggel korrigált életév (quality-adjusted life year, QALY) mutatószám számítására használhatók. Kevés ismerettel rendelkezünk arról, hogy Magyarországon milyen betegségekben állnak rendelkezésre idoalkuval mért hasznosságértékek. Célkituzés: Célunk szisztematikus irodalmi áttekintés keretében összefoglalni és katalogizálni az idoalku módszerrel mért hasznosságértékeket közlo publikációkat Magyarországon. Módszer: 2020 januárjában szisztematikus folyóirat-keresést végeztünk a PubMed, Web of Science és Matarka elektronikus adatbázisokban. Beválogatási kritériumaink a következok voltak: (1) eredeti közlemények, melyek (2) idoalku módszerrel mértek hasznosságértéket, és (3) magyarországi mintán mért adatokat közöltek. Eredmények: 9 eredeti közleményt válogattunk be, amelyek összesen 7 krónikus betegségben (Crohn-betegség, idoskori maculadegeneratio, krónikus migrén, pemphigus, psoriasis, primer dysmenorrhoea és rheumatoid arthritis) 23 egészségi állapot hasznosságát határozták meg. A kutatások mintanagysága 108 és 1996 fo között alakult. Két kutatás betegcsoportokat vizsgált, ketto az általános populációt, és három vizsgálatban szerepelt mindketto. Hat kutatás használta a hagyományos idoalku valamelyik formáját, egy pedig az összetett idoalku módszert. Egy kutatásban szerepelt 'rosszabb a halálnál' válaszlehetoség. A leggyakrabban alkalmazott idotáv a standard 10 év volt (71%). Az egyes állapotok hasznosságának átlaga 0,34 (kezeletlen pemphigus vulgaris) és 0,94 (enyhe primer dysmenorrhoea) között változott. A 'non-traderek' aránya az egyes kutatásokban 0 és 29% között változott. Következtetések: Egyre több krónikus betegségben elérhetok a magyar társadalom vagy betegek preferenciáin alapuló egészséghasznosság-értékek. A hazai idoalku-vizsgálatok többsége megfelel a nemzetközi minoségi követelményeknek. Az idoalku módszer alkalmazása javasolt más krónikus állapotokban is, a felmért hasznosságértékek segíthetik az egészségügyi technológiákkal kapcsolatos finanszírozói döntéshozatalt. Orv Hetil. 2021; 162(14): 542-554. INTRODUCTION: Time trade-off (TTO) is a widely used method to assess health-related quality of life and health utilities for economic evaluations of health technologies. Little is known about the use of TTO in the Hungarian context. OBJECTIVE: To systematically summarize the existing literature on the method in Hungary. METHOD: In January 2020, we conducted a systematic literature search in three electronic databases (MEDLINE, Web of Science and the Hungarian Periodicals Table of Contents Database). Our inclusion criteria were: (1) original publications, which (2) measured utilities by using TTO, (3) from a Hungarian sample. RESULTS: Nine publications containing seven original studies were included that reported utilities for 23 different health states in seven chronic diseases (age-related macular degeneration, chronic migraine, Crohn's disease, pemphigus, primary dysmenorrhoea, psoriasis and rheumatoid arthritis). Sample sizes ranged from 108 to 1996 respondents. Two studies used general population samples, another two used patient groups and three studies used both. Six studies used a form of conventional TTO and one used composite TTO method. The most frequent timeframe was 10 years (71%). The lowest mean utility was 0.34 (uncontrolled pemphigus vulgaris), while the highest was 0.94 (mild primary dysmenorrhoea). The overall proportion of non-traders ranged between 0 and 29% across studies. CONCLUSIONS: A growing number of studies are using TTO to assess utilities for chronic conditions from the general population or patients in Hungary. The majority of Hungarian TTO studies have met international quality standards. The assessment of TTO utilities is recommended also in other chronic conditions to assist health technology assessment. Orv Hetil. 2021; 162(14): 542-554.

Primed to vocalize: Wild-derived male house mice increase vocalization rate and diversity after a previous encounter with a female.

Males in a wide variety of taxa, including insects, birds and mammals, produce vocalizations to attract females. Male house mice emit ultrasonic vocalizations (USVs), especially during courtship and mating, which are surprising complex. It is often suggested that male mice vocalize at higher rates after interacting with a female, but the evidence is mixed depending upon the strain of mice. We conducted a study with wild-derived house mice (Mus musculus musculus) to test whether male courtship vocalizations (i.e., vocalizations emitted in a sexual context) are influenced by a prior direct interaction with a female, and if so, determine how long the effect lasts. We allowed sexually naïve males to directly interact with a female for five minutes (sexual priming), and then we recorded males'vocalizations either 1, 10, 20, or 30 days later when presented with an unfamiliar female (separated by a perforated partition) and female scent. We automatically detected USVs and processed recordings using the Automatic Mouse Ultrasound Detector (A-MUD version 3.2), and we describe our improved version of this tool and tests of its performance. We measured vocalization rate and spectro-temporal features and we manually classified USVs into 15 types to investigate priming effects on vocal repertoire diversity and composition. After sexual priming, males emitted nearly three times as many USVs, they had a larger repertoire diversity, and their vocalizations had different spectro-temporal features (USV length, slope and variability in USV frequency) compared to unprimed controls. Unprimed control males had the most distinctive repertoire composition compared to the primed groups. Most of the effects were found when comparing unprimed to all primed males (treatment models), irrespective of the time since priming. Timepoint models showed that USV length increased 1 day after priming, that repertoire diversity increased 1 and 20 days after priming, and that the variability of USV frequencies was lower 20 and 30 days after priming. Our results show that wild-derived male mice increased the number and diversity of courtship vocalizations if they previously interacted with a female. Thus, the USVs of house mice are not only context-dependent, they depend upon previous social experience and perhaps the contexts of these experiences. The effect of sexual priming on male courtship vocalizations is likely mediated by neuro-endocrine-mechanisms, which may function to advertise males' sexual arousal and facilitate social recognition.

Smoking prevalence and desire to quit among employees in Transylvanian foster care homes.

OBJECTIVES: Few studies have investigated smoking habits among foster care home children and employees, who are at high risk for smoking. Additionally, there are no published studies on the intention to quit smoking among employees of the Romanian Child Protection system, a gap we address in this manuscript. METHODS: A repeated cross-sectional survey was conducted among foster care employees in three Transylvanian counties (Mures, Sibiu, Covasna) in January 2014 to February 2015 (baseline) and September-December 2016 (follow-up). A foster home-based smoking prevention and cessation intervention targeting employees and children was conducted between the two waves. Multivariate logistic regression analysis was conducted to determine associations between socio-demographics, reasons for smoking, tobacco use patterns, reasons for quitting, and tobacco policy attitudes on intention to quit (dependent variable), controlling for participation in the smoking prevention intervention. RESULTS: 305 employees participated in the baseline (76.4% of females, 23.6% of males) and 304 employees in the follow-up surveys (68.8% of females, 31.2% of males) after the smoking prevention and cessation intervention. At baseline, 34.8% of respondents reported that no one was smoking within the foster care home, which increased to 59.1% at follow-up (p < 0.001). Being male and a high level of professional satisfaction were the only correlates of intention to quit in the bivariate models at baseline. Professional satisfaction and a belief that smoking is bad for one's health were the only correlates of intention to quit at follow-up. In multivariable models, professional satisfaction was the only consistent predictor of intention to quit at both time points (OR 5.63, 95% CI 1.71-18.56; OR 4.98, 95% CI 1.43-17.30). CONCLUSIONS: Efforts should be made to promote cessation among foster care employees that includes evidence-based support, along with compliance to policies that prohibit smoking indoors to reinforce cessation efforts.

Frames for the Solution of Operator Equations in Hilbert Spaces with Fixed Dual Pairing.

For the solution of operator equations, Stevenson introduced a definition of frames, where a Hilbert space and its dual are not identified. This means that the Riesz isomorphism is not used as an identification, which, for example, does not make sense for the Sobolev spaces H 0 1 ( Ω ) and H - 1 ( Ω ) . In this article, we are going to revisit the concept of Stevenson frames and introduce it for Banach spaces. This is equivalent to ℓ 2 -Banach frames. It is known that, if such a system exists, by defining a new inner product and using the Riesz isomorphism, the Banach space is isomorphic to a Hilbert space. In this article, we deal with the contrasting setting, where H and H ' are not identified, and equivalent norms are distinguished, and show that in this setting the investigation of ℓ 2 -Banach frames make sense.

Patterns of alternative tobacco product experimentation among ever smoker adolescents.

OBJECTIVES: Alternative tobacco product (ATP) use is popular among adolescents in Western countries, however, little is known about factors influencing ATP experimentation in Europe. The aim of this study was to explore factors associated with ATP experimentation, and to identify patterns of ATP experimentation among Hungarian adolescents who had ever tried manufactured cigarette smoking. METHODS: Logistic regression analyses were applied to estimate the relationship between individual cigarette smoking experiences, social smoking influences, demographics, and ATP experimentation (roll-your-own (RYO) cigarettes, cigars/cigarillos, waterpipe, traditional pipe and flavoured cigarettes) in a cross-sectional sample of 8th and 11th grade students (N = 1,067, 56.0% of girls) who had ever tried manufactured cigarette smoking in six metropolitan cities of Hungary. Latent class analysis (LCA) was performed to identify patterns of different ATP use. RESULTS: Almost 90% of the sample had ever tried ATPs and significantly more commonly older (91.8%) versus younger (79.8%) students. Waterpipe was the most popular product to try followed by flavoured cigarettes, cigars/cigarillos, RYO cigarettes, and pipe. Boys were more likely to report ATP experimentation compared to girls. Younger age of cigarette smoking experimentation, greater frequency of past month cigarette smoking and history of ever daily smoking for 30 days showed strong association with ATP experimentation. Students with one or more smoking friends were more vulnerable to experiment with ATPs. Weekly allowance, school academic achievement and household smoking exposure showed no effect on the experimentation. LCA identified four subgroups of ATP experimenters comprising intense polytobacco experimenters (38.4%), mainly waterpipe experimenters (34.2%), moderate polytobacco experimenters (14.9%), and less interested experimenters (12.5%). CONCLUSION: Tobacco prevention programmes targeting adolescents should emphasize the risks of using ATPs in addition to manufactured cigarettes. Accessibility of ATPs should be better regulated and restrictions should be strongly enforced in order to prevent potential harmful consequences of adolescent polytobacco use.

[The historic master key to get rid of medical doctors' informal payment]. / Az orvosi hálapénz megoldásának történelmi kulcsa.

There is no nation in the developed world without dysfunctions of its health care system. The cause behind is universal since it goes back to the historic conflict of private and public financing of services. Phenomena on the surface are multi-faceted, in Hungary they are concentrated in the doctors' informal payment the original pattern of which was emerging three centuries ago. While neglecting our series of mismanagement, all our new initiatives will disable any real solution. The world's best health system models in Germany and the United Kingdom function without informal payment. Their substantial models compromise private and public financing. Instead of questionable ideas, Hungary needs to find its own relevant solution based on a new deal with the society but it must have a firm base of scientific evidences. Orv Hetil. 2019; 160(2): 50-56.

Continued smoking versus spontaneous quitting among pregnant women living in a high risk environment.

OBJECTIVES: In Hungary, 37% of women living in poverty were smokers in 2012. There are no valid data of pregnant women's spontaneous smoking cessation. METHODS: Our retrospective cohort study (2009-2012) targeted the most underdeveloped regions with an estimated 6-8.5% of Roma population. The sample (N = 12,552) represented 76% of the target population i.e. women in four counties in a year delivering live born babies. Chi-square probe and multivariable logistic regression model (p < 0.05) were used to assess relationship between socio-demographic characteristics and spontaneous cessation. RESULTS: Prior to pregnancy, the overall smoking rate was 36.8%. That of women in deep poverty and Roma was 49.7% and 51.1%, respectively. 70.3% of smokers continued smoking during the pregnancy. Among them 80.6% lived in deep poverty. Spontaneous quitting rate was 23.0%. Factors correlated with continued smoking included being Roma (OR = 1.95), undereducated (OR = 2.66), living in homes lacking amenities (OR = 1.48), and having regularly smoking partner (OR = 2.07). Cessation was promoted by younger age (≤ 18 years) (OR = 0.18), being married (OR = 0.50), and the first pregnancy. CONCLUSIONS: Tailored cessation programmes are needed for Roma, older, low-income, and multiparous women who are less likely to quit on their own. Engaging husbands/partners is essential to reduce smoking among pregnant women and second-hand smoke exposure.

Home- and Car-Based Rules in Foster Care Settings to Reduce Exposure to Secondhand Smoke: Before and after Romanian National Clean Air Legislation.

Background: To evaluate changes in smoke free rules in the foster care system after the implementation of the Romanian national clean air law. Methods: A repeated cross-sectional, self-administered questionnaire among foster care employees (n = 599) was conducted in 58 foster care homes during 2014 (n = 295) and 51 homes during 2016 (n = 304). We estimated the absolute difference in the proportion of employees who stated that smoke free rules existed before and after national clean air legislation. Results: There was an absolute increase in 4 of 5 smoke free measures after the law: bans on non-cigarette tobacco products (n = 169 to 206, +10.6%), non-smoking on premises for adults (n = 142 to 202, +18.3%), and for children (n = 201 to 239, +10.3%), and no smoking in cars to transport children (n = 194 to 227, +9%). There was a significant increase in the perception of outdoor bans that prohibit employees from smoking on foster care home premises (AOR 2.24, 95% CI 1.14⁻4.38). The increase in the perception of indoor smoking bans did not change. Conclusion: The national law may have had a spillover influence by strengthening smoke free rules in unregulated spaces. Nonetheless, foster care home rules could be further enhanced, particularly in cars that transport children.