End-of-life care in an Australian acute hospital: a retrospective observational study.

BACKGROUND: There is a gap in knowledge about the kind and quality of care experienced by hospital patients at the end of their lives. AIMS: To document and compare the patterns in end-of-life care for patients dying across a range of different medical units in an acute care hospital. METHODS: A retrospective observational study of consecutive adult inpatient deaths between 1 July 2010 and 30 June 2014 in four different medical units of an Australian tertiary referral hospital was performed. Units were selected on the basis of highest inpatient death rates and included medical oncology, respiratory medicine, cardiology and gastroenterology/hepatology. RESULTS: Overall, 41% of patients died with active medical treatment plans, but significantly more respiratory and cardiology patients died with ongoing treatment (46 and 75% respectively) than medical oncology and gastroenterology patients (each 27%, P < 0.05). More medical oncology and gastroenterology patients were recognised as dying (92 and 88%) compared with 72% of respiratory and only 38% of cardiology patients (P < 0.001). Significantly, more medical oncology patients were referred to palliative care and received comfort care plans than all other patient groups. However, the rate of non-palliative interventions given in the final 48 h was not significantly different between all four groups. CONCLUSIONS: There were differences in managing the dying process between all disciplines. A possible solution to these discrepancies would be to create an integrated palliative care approach across the hospital. Improving and reducing interdisciplinary practice variations will allow more patients to have a high-quality and safe death in acute hospitals.

Effects of plain packaging, warning labels, and taxes on young people's predicted sugar-sweetened beverage preferences: an experimental study.

BACKGROUND: Consumption of sugar-sweetened beverages (SSBs) is associated with increased risk of obesity, diabetes, heart disease and dental caries. Our aim was to assess the effects of plain packaging, warning labels, and a 20 % tax on predicted SSB preferences, beliefs and purchase probabilities amongst young people. METHODS: A 2 × 3 × 2 between-group experimental study was conducted over a one-week period in August 2014. Intervention scenarios were delivered, and outcome data collected, via an anonymous online survey. Participants were 604 New Zealand young people aged 13-24 years who consumed soft drinks regularly. Participants were randomly allocated using a computer-generated algorithm to view one of 12 experimental conditions, specifically images of branded versus plain packaged SSBs, with either no warning, a text warning, or a graphic warning, and with or without a 20 % tax. Participant perceptions of the allocated SSB product and of those who might consume the product were measured using seven-point Likert scales. Purchase probabilities were measured using 11-point Juster scales. RESULTS: Six hundred and four young people completed the survey (51 % female, mean age 18 (SD 3.4) years). All three intervention scenarios had a significant negative effect on preferences for SSBs (plain packaging: F (6, 587) = 54.4, p <0.001; warning label: F (6, 588) = 19.8, p <0.001; 20 % tax: F (6, 587) = 11.3, p <0.001). Plain packaging and warning labels also had a significant negative impact on reported likelihood of purchasing SSB's (p = <0.001). A 20 % tax reduced participants' purchase probability but the difference was not statistically significant (p = 0.2). CONCLUSIONS: Plain packaging and warning labels significantly reduce young people's predicted preferences for, and reported probability of purchasing, SSBs.

Interpretive front-of-pack nutrition labels. Comparing competing recommendations.

Many stakeholders support introducing an interpretive front-of-pack (FOP) nutrition label, but disagree over the form it should take. In late 2012, an expert working group established by the New Zealand government recommended the adoption of an untested summary rating system: a Star label. This study used a best-worst scaling choice experiment to estimate how labels featuring the new Star rating, the Multiple Traffic Light (MTL), Daily Intake Guide (DIG), and a no-FOP control affected consumers' choice behaviours and product perceptions. Nutrient-content and health claims were included in the design. We also assessed whether respondents who used more or less information during the choice tasks differed in their selection patterns. Overall, while respondents made broadly similar choices with respect to the MTL and Star labels, the MTL format had a significantly greater impact on depressing preference as a food's nutritional profile became less healthy. Health claims increased rankings of less nutritious options, though this effect was less pronounced when the products featured an MTL. Further, respondents were best able to differentiate products' healthiness with MTL labels. The proposed summary Stars system had less effect on choice patterns than an MTL label and our findings highlight the need for policy makers to ensure that decisions to introduce FOP labels are underpinned by robust research evidence. These results suggest that the proposed summary Stars system will have less effect on shifting food choice patterns than interpretive FOP nutrition label featuring traffic light ratings.

Social smokers' management of conflicted identities.

BACKGROUND: Although social smoking has increased among young adults, it remains a poorly understood behaviour. The authors explored how young adult social smokers viewed and defined smoking and the strategies they used to reconcile their conflicting smoker and non-smoker identities. The authors also examined alcohol's role in facilitating social smoking and investigated measures that would decouple drinking and smoking. METHODS: The authors conducted 13 in-depth interviews with young adult social smokers aged between 19 and 25 years and used thematic analysis to interpret the transcripts. RESULTS: The authors identified four key themes: the demarcation strategies social smokers used to avoid classifying themselves as smokers, social smoking as a tactic that ameliorates the risk of alienation, alcohol as a catalyst of social smoking and the difficulty participants experienced in reconciling their identity as non-smokers who smoke. CONCLUSIONS: Although social smokers regret smoking, their retrospective remorse was insufficient to promote behaviour change, and environmental modifications appear more likely to promote smoke-free behaviours among social smokers. Participants strongly supported extending the smoke-free areas outside bars, a measure that would help decouple their alcohol-fuelled behaviours from the identity to which they aspire.

'The times are changing': New Zealand smokers' perceptions of the tobacco endgame.

BACKGROUND: The New Zealand government's goal of achieving a smoke-free society by 2025 reflects growing interest in 'endgame' solutions to tobacco smoking. However, tobacco companies have framed 'endgame' strategies as contrary to individual freedoms and 'choice'; these claims heighten politicians' sensitivity to 'nanny state' allegations and may undermine tobacco control policies. Public support for stronger policies could strengthen political will; however, little is known about how smokers perceive endgame scenarios or the factors underlying their support or opposition to these. METHODS: The authors conducted 47 in-depth interviews with four priority groups: Maori, Pacific, young adults and pregnant women; all were smokers or very recent quitters. The authors used thematic analysis to interpret the transcripts. RESULTS: Most participants strongly supported the 2025 smoke-free goal, recognised the broader social good that would result and accepted the personal inconvenience of quitting. Yet they wanted to retain control over when and how they would quit and asserted their 'freedom' to smoke. Participants identified interventions that would extend current policy and maintain the autonomy they valued; the authors classified these into four themes: restricting supply, diminishing visibility, decreasing availability and affordability, and increasing quit support. CONCLUSIONS: Politicians may have a stronger mandate to implement endgame policies than they appreciate. Participants' use of industry arguments when asserting their freedom to 'choose' to smoke and quit suggests a need for denormalisation strategies that challenge industry propaganda, demonstrate how endgame measures would empower smokers and re-iterate the community benefits a smoke-free society will deliver.

An exploration of parents' food purchasing behaviours.

A qualitative study explored factors that influence parents' food purchasing behaviours in supermarkets and away-from-home settings, particularly the role played by nutrition information. Individual in-depth interviews were conducted with 15 parents of young children in a provincial city in New Zealand. A semi-structured protocol was used to elicit factors influencing food purchases and explore the understanding and influence of existing nutrition labels. Thematic analysis revealed that while parents wish to select good food for their families, practical factors dominate their decisions. Nutrition labels had little reported influence on food choice, largely because parents face competing demands when selecting food for their families. These factors militate against use of detailed nutrition information, especially formats that require considerable effort to comprehend.

A qualitative analysis of messages to promote smoking cessation among pregnant women.

OBJECTIVES: Although aware that smoking while pregnant presents serious risks to their unborn children, some women continue to smoke and rationalise their dissonance rather than quit. We explored metaphors women used to frame smoking and quitting, then developed cessation messages that drew on these metaphors and examined the perceived effectiveness of these. PARTICIPANTS: We used a two-phase qualitative study. Phase one involved 13 in-depth interviews with women who were smoking (or who had smoked) while pregnant. Phase two comprised 22 in-depth interviews with a new sample drawn from the same population. ANALYSES: Data were analysed using thematic analysis, which promoted theme identification independently of the research protocol. RESULTS: Participants often described smoking as a choice, a frame that explicitly asserted control over their behaviour. This stance allowed them to counter-argue messages to quit, and distanced them from the risks they created and faced. Messages tested in phase 2 used strong affective appeals as well as themes that stimulated cognitive reflection. Without exception, the messages depicting unwell or distressed children elicited strong emotional responses, were more powerful cessation stimuli, and elicited fewer counter-arguments. CONCLUSIONS: Cessation messages that evoke strong affective responses capitalise on the dissonance many women feel when smoking while pregnant and stimulate stronger consideration of quitting. Given the importance of promoting cessation among pregnant women, future campaigns could make greater use of emotional appeals and place less emphasis on informational approaches, which often prompt vigorous counter-arguments.

Public support for more action on smoking.

An online survey of 414 smokers and 414 non-smokers found strong support among New Zealanders for more tobacco control interventions. In particular, support for interventions that will protect children--smokefree playgrounds and smokefree cars when children are in them--was very high among both smokers and non-smokers. Predictably, non-smokers were more likely than smokers to support other tobacco control interventions including extending outdoor smokefree areas and restricting the availability of tobacco. Nevertheless, there was widespread support for the tobacco 'end game' goal of reducing smoking prevalence from around 20% to 5% or less by 2025. These results are consistent with growing evidence of public support for stronger tobacco control interventions and confirm that preventive health measures have broad public appeal.

Consumers' knowledge, perceptions, and responsiveness to direct-to-consumer advertising of prescription medicines.

AIM: This research explored whether direct-to-consumer-advertising of prescription medicines (DTCA) increased disadvantaged consumers' knowledge of important health issues and encouraged those with lower health knowledge to consult their doctor (as has been argued by supporters of DTCA). METHOD: A mail survey of 1042 New Zealanders was undertaken between October and December 2002 using a stratified random sample drawn from the electoral roll. After two reminders were sent, 632 completed questionnaires were returned (64% response rate). We examined the relationship between respondents' self-assessed knowledge of health-related issues, their perceived health status, and their response to DTCA (using self-efficacy theory to aid interpretation of the results). RESULTS: Respondents with greater health knowledge found DTCA easier to understand and were more likely to have sought further information about an advertised medicine than those with less knowledge. CONCLUSIONS: These results suggest DTCA may reinforce existing knowledge rather than educate or provide new knowledge. The results also cast doubt upon claims that DTCA enhances awareness of health issues among groups with lower health knowledge thus helping them overcome barriers to better health. Although changes to DTCA regulation could increase the information conveyed by this advertising, the advertising and pharmaceutical industries' failure to respond to well-documented concerns about DTCA raises serious questions about the power of policy refinements to control advertisers' conduct.

New Zealand general practitioners' views on direct-to-consumer advertising of prescription medicines: a qualitative analysis.

AIM: To explore the range of opinions held by a sample of New Zealand general practitioners (GPs) toward direct-to-consumer advertising (DTCA) of prescription medicines. METHOD: Depth interviews were conducted with 20 GPs. The interview protocol examined several aspects of the debate over DTCA, including its appropriateness, informativeness, and effect on doctors' relationships with their patients. The interview included five sets of forced choice statements that summarised key strands of the debate; these were used as preliminary stimuli to elicit doctors' views. RESULTS: The results reveal a low incidence of DTCA-related queries and a wide range of views on the appropriateness of DTCA. Respondents favourably viewed DTCA's ability to increase awareness of some health conditions, although they had serious concerns about the adequacy of the risk and contraindication information provided as well as the general absence of specific cost details. While some doctors resented having to deal with questions arising from DTCA, few considered that this advertising undermined the relationship they have with their patients. CONCLUSIONS: Overall, while the majority of respondents did not support a ban on DTCA, most of them thought that stricter regulation was necessary. These findings clarify the conclusions drawn from quantitative studies, and suggest doctors' views of DTCA may be more complex than previously reported.