Implementation of a digital exercise programme in health services to prevent falls in older people.

BACKGROUND: StandingTall uses eHealth to deliver evidence-based balance and functional strength exercises. Clinical trials have demonstrated improved balance, reduced falls and fall-related injuries and high adherence. This study aimed to evaluate the implementation of StandingTall into health services in Australia and the UK. METHODS: Two hundred and forty-six participants (Australia, n = 184; UK, n = 62) were recruited and encouraged to use StandingTall for 2 h/week for 6-months. A mixed-methods process evaluation assessed uptake and acceptability of StandingTall. Adherence, measured as % of prescribed dose completed, was the primary outcome. RESULTS: The study, conducted October 2019 to September 2021 in Australia and November 2020 to April 2022 in the UK, was affected by COVID-19. Participants' mean age was 73 ± 7 years, and 196 (81%) were female. Of 129 implementation partners (e.g. private practice clinicians, community exercise providers, community service agencies) approached, 34% (n = 44) agreed to be implementation partners. Of 41 implementation partners who referred participants, 15 (37%) referred ≥5. Participant uptake was 42% (198/469) with mean adherence over 6 months being 41 ± 39% of the prescribed dose (i.e. 39 ± 41 min/week) of exercise. At 6 months, 120 (76%) participants indicated they liked using StandingTall, 89 (56%) reported their balance improved (moderately to a great deal better) and 125 (80%) rated StandingTall as good to excellent. For ongoing sustainability, health service managers highlighted the need for additional resources. CONCLUSIONS: StandingTall faced challenges in uptake, adoption and sustainability due to COVID-19 and a lack of ongoing funding. Adherence levels were lower than the effectiveness trial, but were higher than other exercise studies. Acceptance was high, indicating promise for future implementation, provided sufficient resources and support are made available. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12619001329156.

The effects of active classroom breaks on moderate to vigorous physical activity, behaviour and performance in a Northern NSW primary school: A quasi-experimental study.

ISSUE ADDRESSED: Approximately 77% of NSW children aged 5 to 15 years do not meet physical activity guidelines and many spend a considerable amount of time sitting. Active breaks at primary school are feasible, may increase daily moderate to vigorous physical activity (MVPA) and decrease off-task behaviour without adversely affecting cognitive function and learning. METHODS: In this quasi-experimental study, 101 primary school children in six intervention classrooms participated in three 10-minute active breaks per day for six-weeks during class time, while five control classrooms were run as usual (n = 89). Physical activity levels were measured using wrist-worn Actigraph wGT3X-BT accelerometers and analysed using a random forest model. Students' off-task behaviour, wellbeing, cognitive function and maths performance were also measured. School staff completed a brief feedback survey. RESULTS: Children in the intervention group engaged in 15.4 and 10.9 minutes more MVPA per day at 3 and 6 weeks respectively (P < .001). Participation significantly increased the proportion of children who met the Australian 24-Hour Movement Guidelines (P < .001). At pre, middle and end of intervention, 44.4%, 60.8% and 55.1% of intervention children and 46.5%, 45.9% and 45.8% of controls met the guidelines. Significantly fewer students engaged in off-task behaviour in the intervention classes at mid and final weeks of intervention (-1.4 students, P = .003). No significant intervention effects were found for wellbeing, cognitive and maths performance. CONCLUSIONS: Active classroom breaks are an effective way to increase physical activity among primary school children while reducing off-task classroom behaviour. SO WHAT?: Primary school students' health would benefit from active breaks with no detrimental effects on wellbeing, maths and cognitive performance.

Applying the Ottawa Charter to inform health promotion programme design.

There is evidence of a correlation between adoption of the Ottawa Charter's framework of five action areas and health promotion programme effectiveness, but the Charter's framework has not been as fully implemented as hoped, nor is generally used by formal programme design models. In response, we aimed to translate the Charter's framework into a method to inform programme design. Our resulting design process uses detailed definitions of the Charter's action areas and evidence of predicted effectiveness to prompt greater consideration and use of the Charter's framework. We piloted the process by applying it to the design of four programmes of the Healthy Children's Initiative in New South Wales, Australia; refined the criteria via consensus; and made consensus decisions on the extent to which programme designs reflected the Charter's framework. The design process has broad potential applicability to health promotion programmes; facilitating greater use of the Ottawa Charter framework, which evidence indicates can increase programme effectiveness.

Integrating relationship- and research-based approaches in Australian health promotion practice.

We examine the perspectives of health promotion practitioners on their approaches to determining health promotion practice, in particular on the role of research and relationships in this process. Using Grounded Theory methods, we analysed 58 semi-structured interviews with 54 health promotion practitioners in New South Wales, Australia. Practitioners differentiated between relationship-based and research-based approaches as two sources of knowledge to guide health promotion practice. We identify several tensions in seeking to combine these approaches in practice and describe the strategies that participants adopted to manage these tensions. The strategies included working in an evidence-informed rather than evidence-based way, creating new evidence about relationship-based processes and outcomes, adopting 'relationship-based' research and evaluation methods, making research and evaluation useful for communities, building research and evaluation skills and improving collaboration between research and evaluation and programme implementation staff. We conclude by highlighting three systemic factors which could further support the integration of research-based and relationship-based health promotion practices: (i) expanding conceptions of health promotion evidence, (ii) developing 'relationship-based' research methods that enable practitioners to measure complex social processes and outcomes and to facilitate community participation and benefit, and (iii) developing organizational capacity.

Making sense in a complex landscape: how the Cynefin Framework from Complex Adaptive Systems Theory can inform health promotion practice.

Health promotion addresses issues from the simple (with well-known cause/effect links) to the highly complex (webs and loops of cause/effect with unpredictable, emergent properties). Yet there is no conceptual framework within its theory base to help identify approaches appropriate to the level of complexity. The default approach favours reductionism--the assumption that reducing a system to its parts will inform whole system behaviour. Such an approach can yield useful knowledge, yet is inadequate where issues have multiple interacting causes, such as social determinants of health. To address complex issues, there is a need for a conceptual framework that helps choose action that is appropriate to context. This paper presents the Cynefin Framework, informed by complexity science--the study of Complex Adaptive Systems (CAS). It introduces key CAS concepts and reviews the emergence and implications of 'complex' approaches within health promotion. It explains the framework and its use with examples from contemporary practice, and sets it within the context of related bodies of health promotion theory. The Cynefin Framework, especially when used as a sense-making tool, can help practitioners understand the complexity of issues, identify appropriate strategies and avoid the pitfalls of applying reductionist approaches to complex situations. The urgency to address critical issues such as climate change and the social determinants of health calls for us to engage with complexity science. The Cynefin Framework helps practitioners make the shift, and enables those already engaged in complex approaches to communicate the value and meaning of their work in a system that privileges reductionist approaches.

Supporting adolescents' participation in muscle-strengthening physical activity: protocol for the 'Resistance Training for Teens' (RT4T) hybrid type III implementation-effectiveness trial.

INTRODUCTION: In Australia, only 22% of male and 8% of female adolescents meet the muscle-strengthening physical activity guidelines, and few school-based interventions support participation in resistance training (RT). After promising findings from our effectiveness trial, we conducted a state-wide dissemination of the 'Resistance Training for Teens' (RT4T) intervention from 2015 to 2020. Despite high estimated reach, we found considerable variability in programme delivery and teachers reported numerous barriers to implementation. Supporting schools when they first adopt evidence-based programmes may strengthen programme fidelity, sustainability, and by extension, programme impact. However, the most effective implementation support model for RT4T is unclear. OBJECTIVE: To compare the effects of three implementation support models on the reach (primary outcome), dose delivered, fidelity, sustainability, impact and cost of RT4T. METHODS AND ANALYSIS: We will conduct a hybrid type III implementation-effectiveness trial involving grade 9 and 10 (aged 14-16 years) students from 90 secondary schools in New South Wales (NSW), Australia. Schools will be recruited across one cohort in 2023, stratified by school type, socioeconomic status and location, and randomised in a 1:1:1 ratio to receive one of the following levels of implementation support: (1) 'low' (training and resources), (2) 'moderate' (training and resources+external support) or 'high' (training and resources+external support+equipment). Training includes a teacher workshop related to RT4T programme content (theory and practical sessions) and the related resources. Additional support will be provided by trained project officers from five local health districts. Equipment will consist of a pack of semiportable RT equipment (ie, weighted bars, dumbbells, resistance bands and inverted pull up bar stands) valued at ~$A1000 per school. Study outcomes will be assessed at baseline (T0), 6 months (T1) and 18 months (T2). A range of quantitative (teacher logs, observations and teacher surveys) and qualitative (semistructured interviews with teachers) methods will be used to assess primary (reach) and secondary outcomes (dose delivered, fidelity, sustainability, impact and cost of RT4T). Quantitative analyses will use logistic mixed models for dichotomous outcomes, and ordinal or linear mixed effects regression models for continuous outcomes, with alpha levels set at p<0.025 for the outcomes and cost comparisons of the moderate and high support arms against the low support arm. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the University of Newcastle (H-2021-0418), the NSW Department of Education (SERAP:2022215), Hunter New England Human Research Ethics Committee (2023/ETH00052) and the Catholic Schools Office. The design, conduct and reporting will adhere to the Consolidated Standards of Reporting Trials statement, the Standards for Reporting Implementation Studies statement and the Template for Intervention Description and Replication checklist. Findings will be published in open access peer-reviewed journals, key stakeholders will be provided with a detailed report. We will support ongoing dissemination of RT4T in Australian schools via professional learning for teachers. TRIAL REGISTRATION NUMBER: ACTRN12622000861752.

Three year follow-up of an early childhood intervention: is movement skill sustained?

BACKGROUND: Movement skill competence (e.g. the ability to throw, run and kick) is a potentially important physical activity determinant. However, little is known about the long-term impact of interventions to improve movement skills in early childhood. This study aimed to determine whether intervention preschool children were still more skill proficient than controls three years after a 10 month movement skill focused intervention: 'Tooty Fruity Vegie in Preschools'. METHODS: Children from 18 intervention and 13 control preschools in NSW, Australia were assessed at ages four (Time1), five (T2) and eight years (T3) for locomotor (run, gallop, hop, leap, horizontal jump, slide) and object control proficiency (strike, bounce, catch, kick, overhand throw, underhand roll) using the Test of Gross Motor Development-2. Multi-level object control and locomotor regression models were fitted with variables time, intervention (yes/no) and a time*intervention interaction. Both models added sex of child and retained if significant, in which case interactions of sex of child with other variables were modelled and retained. SPSS (Version 17.0) was used. RESULTS: Overall follow-up rate was 29% (163/560). Of the 137 students used in the regression models, 53% were female (n = 73). Intervention girls maintained their object control skill advantage in comparison to controls at T3 (p = .002), but intervention boys did not (p = .591). At T3, there were no longer intervention/control differences in locomotor skill (p = .801). CONCLUSION: Early childhood settings should implement movement skill interventions and more intensively target girls and object control skills.

Tooty Fruity Vegie: an obesity prevention intervention evaluation in Australian preschools.

ISSUES ADDRESSED: This paper presents the findings from a cluster randomised controlled evaluation of a preschool-based intervention (children aged 3-6 years), on the North Coast of NSW, which aimed to decrease overweight and obesity prevalence among children by improving fundamental movement skills (FMS), increasing fruit and vegetable intake and decreasing unhealthy food consumption. METHODS: The Tooty Fruity Vegie in Preschools program was implemented in 18 preschools for 10 months during 2006 and 2007. It included nutrition and physical activity strategies. Pre and post intervention evaluation compared intervention and control children and was conducted at the beginning and end of each year. It included FMS testing, lunch box audits and anthropometric measures of children as well as parents' surveys regarding children's food intake, physical activity and sedentary behaviours. RESULTS: In comparison to controls, children in intervention preschools significantly improved movement skills (14.79 units, p<0.001), had more fruit and vegetable serves (0.63 serves, p=0.001) and were less likely to have unhealthy food items (p<0.001) in their lunch boxes following the intervention. There was also a significant difference in waist circumference growth (-0.80 cm, p=0.002) and a reduction of BMI Z scores (-0.15, p=0.022). CONCLUSIONS: The 10-month intervention in preschools produced significant changes in children's food intake, movement skills and indicators of weight status.

Evidence, ethics, and values: a framework for health promotion.

We propose a new approach to guide health promotion practice. Health promotion should draw on 2 related systems of reasoning: an evidential system and an ethical system. Further, there are concepts, values, and procedures inherent in both health promotion evidence and ethics, and these should be made explicit. We illustrate our approach with the exemplar of intervention in weight, and use a specific mass-media campaign to show the real-world dangers of intervening with insufficient attention to ethics and evidence. Both researchers and health promotion practitioners should work to build the capacities required for evidential and ethical deliberation in the health promotion profession.

Implementation of the StandingTall programme to prevent falls in older people: a process evaluation protocol.

INTRODUCTION: One in three people aged 65 years and over fall each year. The health, economic and personal impact of falls will grow substantially in the coming years due to population ageing. Developing and implementing cost-effective strategies to prevent falls and mobility problems among older people is therefore an urgent public health challenge. StandingTall is a low-cost, unsupervised, home-based balance exercise programme delivered through a computer or tablet. StandingTall has a simple user-interface that incorporates physical and behavioural elements designed to promote compliance. A large randomised controlled trial in 503 community-dwelling older people has shown that StandingTall is safe, has high adherence rates and is effective in improving balance and reducing falls. The current project targets a major need for older people and will address the final steps needed to scale this innovative technology for widespread use by older people across Australia and internationally. METHODS AND ANALYSIS: This project will endeavour to recruit 300 participants across three sites in Australia and 100 participants in the UK. The aim of the study is to evaluate the implementation of StandingTall into the community and health service settings in Australia and the UK. The nested process evaluation will use both quantitative and qualitative methods to explore uptake and acceptability of the StandingTall programme and associated resources. The primary outcome is participant adherence to the StandingTall programme over 6 months. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the South East Sydney Local Health District Human Research Ethics Committee (HREC reference 18/288) in Australia and the North West- Greater Manchester South Research Ethics Committee (IRAS ID: 268954) in the UK. Dissemination will be via publications, conferences, newsletter articles, social media, talks to clinicians and consumers and meetings with health departments/managers. TRIAL REGISTRATION NUMBER: ACTRN12619001329156.

Six year follow-up of students who participated in a school-based physical activity intervention: a longitudinal cohort study.

BACKGROUND: The purpose of this paper was to evaluate the long-term impact of a childhood motor skill intervention on adolescent motor skills and physical activity. METHODS: In 2006, we undertook a follow-up of motor skill proficiency (catch, kick, throw, vertical jump, side gallop) and physical activity in adolescents who had participated in a one-year primary school intervention Move It Groove It (MIGI) in 2000. Logistic regression models were analysed for each skill to determine whether the probability of children in the intervention group achieving mastery or near mastery was either maintained or had increased in subsequent years, relative to controls. In these models the main predictor variable was intervention status, with adjustment for gender, grade, and skill level in 2000. A general linear model, controlling for gender and grade, examined whether former intervention students spent more time in moderate-to-vigorous physical activity at follow-up than control students. RESULTS: Half (52%, n = 481) of the 928 MIGI participants were located in 28 schools, with 276 (57%) assessed. 52% were female, 58% in Grade 10, 40% in Grade 11 and 54% were former intervention students. At follow-up, intervention students had improved their catch ability relative to controls and were five times more likely to be able to catch: ORcatch = 5.51, CI (1.95 - 15.55), but had lost their advantage in the throw and kick: ORthrow = .43, CI (.23 - .82), ORkick = .39, CI (.20 - .78). For the other skills, intervention students appeared to maintain their advantage: ORjump = 1.14, CI (.56 - 2.34), ORgallop = 1.24, CI (.55 - 2.79). Intervention students were no more active at follow-up. CONCLUSION: Six years after the 12-month MIGI intervention, whilst intervention students had increased their advantage relative to controls in one skill, and appeared to maintain their advantage in two, they lost their advantage in two skills and were no more active than controls at follow up. More longitudinal research is needed to explore whether gains in motor skill proficiency in children can be sustained and to determine the intervention characteristics that translate to subsequent physical activity.

Tooty Fruity Vegie in Preschools: an obesity prevention intervention in preschools targeting children's movement skills and eating behaviours.

ISSUE ADDRESSED: This paper outlines the implementation strategies and evaluation methods of the Tooty Fruity Vegie (TFV) in Preschools program in NSW Australia which addressed diet, movement skills and overweight indicators. METHODS: The TFV program was a one-year intervention conducted during 2006 and 2007 in 18 preschools (matched with 13 control preschools). The study had a quasi-experimental design with pre- and postintervention evaluation of nutrition and physical activity variables as well as anthropometric measures. Details of the program's methodological aspects such as the recruitment process, intervention strategies and evaluation instruments are described.

The Mull Hypothesis: is cannabis use contributing to high tobacco use prevalence among young North Coast males?

Men aged 25-34 years, in North Coast NSW, have higher documented smoking rates than elsewhere in the state. The present paper explores potential causes of elevated smoking rates in this population and proposes that tobacco dependence resulting from 'mulling' (mixing) cannabis with tobacco may be contributing.

Creating active playgrounds in primary schools.

ISSUE ADDRESSED: To identify a model for a process that will support schools to implement environmental modifications in playgrounds aimed at increasing physical activity. METHODS: Kidsafe NSW (Playground Advisory Unit) was commissioned by the former Illawarra Health Promotion Unit (IHPU) to develop playground concept designs, safety audits and detailed reports for three primary schools. Each report contained several environmental recommendations to increase participation in physical activity. During this study one school was destroyed by fire. The former IHPU supported the remaining two schools to implement environmental modifications for increasing physical activity through a process of meetings and interviews. RESULTS: Principals of both schools said they found the process to be valuable and it encouraged them to implement changes to their school environment for the purpose of increasing physical activity. School staff and the Parents and Friends Association felt that having a report from Kidsafe NSW increased the credibility and importance of the recommendations. Both schools made several changes to their playgrounds that were recommended in the report. CONCLUSIONS: The process of providing a Kidsafe NSW playground report, as well as support through meetings and interviews, appears to promote environmental change in schools.

Correlates of Gross Motor Competence in Children and Adolescents: A Systematic Review and Meta-Analysis.

BACKGROUND: Gross motor competence confers health benefits, but levels in children and adolescents are low. While interventions can improve gross motor competence, it remains unclear which correlates should be targeted to ensure interventions are most effective, and for whom targeted and tailored interventions should be developed. OBJECTIVE: The aim of this systematic review was to identify the potential correlates of gross motor competence in typically developing children and adolescents (aged 3-18 years) using an ecological approach. METHODS: Motor competence was defined as gross motor skill competency, encompassing fundamental movement skills and motor coordination, but excluding motor fitness. Studies needed to assess a summary score of at least one aspect of motor competence (i.e., object control, locomotor, stability, or motor coordination). A structured electronic literature search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Six electronic databases (CINAHL Complete, ERIC, MEDLINE Complete, PsycINFO®, Scopus and SPORTDiscus with Full Text) were searched from 1994 to 5 August 2014. Meta-analyses were conducted to determine the relationship between potential correlates and motor competency if at least three individual studies investigated the same correlate and also reported standardized regression coefficients. RESULTS: A total of 59 studies were identified from 22 different countries, published between 1995 and 2014. Studies reflected the full range of age groups. The most examined correlates were biological and demographic factors. Age (increasing) was a correlate of children's motor competence. Weight status (healthy), sex (male) and socioeconomic background (higher) were consistent correlates for certain aspects of motor competence only. Physical activity and sport participation constituted the majority of investigations in the behavioral attributes and skills category. Whilst we found physical activity to be a positive correlate of skill composite and motor coordination, we also found indeterminate evidence for physical activity being a correlate of object control or locomotor skill competence. Few studies investigated cognitive, emotional and psychological factors, cultural and social factors or physical environment factors as correlates of motor competence. CONCLUSION: This systematic review is the first that has investigated correlates of gross motor competence in children and adolescents. A strength is that we categorized correlates according to the specific ways motor competence has been defined and operationalized (object control, motor coordination, etc.), which enables us to have an understanding of what correlates assist what types of motor competence. Indeed our findings do suggest that evidence for some correlates differs according to how motor competence is operationalized.

Face validity and reliability of a pictorial instrument for assessing fundamental movement skill perceived competence in young children.

OBJECTIVES: To determine reliability and face validity of an instrument to assess young children's perceived fundamental movement skill competence. DESIGN: Validation and reliability study. METHODS: A pictorial instrument based on the Test Gross Motor Development-2 assessed perceived locomotor (six skills) and object control (six skills) competence using the format and item structure from the physical competence subscale of the Pictorial Scale of Perceived Competence and Acceptance for Young Children. Sample 1 completed object control items in May (n=32) and locomotor items in October 2012 (n=23) at two time points seven days apart. Children were asked at the end of the test-retest their understanding of what was happening in each picture to determine face validity. Sample 2 (n=58) completed 12 items in November 2012 on a single occasion to test internal reliability only. RESULTS: Sample 1 children were aged 5-7 years (M=6.0, SD=0.8) at object control assessment and 5-8 years at locomotor assessment (M=6.5, SD=0.9). Sample 2 children were aged 6-8 years (M=7.2, SD=0.73). Intra-class correlations assessed in Sample 1 children were excellent for object control (intra-class correlation=0.78), locomotor (intra-class correlation=0.82) and all 12 skills (intra-class correlations=0.83). Face validity was acceptable. Internal consistency was adequate in both samples for each subscale and all 12 skills (alpha range 0.60-0.81). CONCLUSIONS: This study has provided preliminary evidence for instrument reliability and face validity. This enables future alignment between the measurement of perceived and actual fundamental movement skill competence in young children.

Three-year follow-up of an early childhood intervention: what about physical activity and weight status?

BACKGROUND: Fundamental movement skills are a correlate of physical activity and weight status. Children who participated in a preschool intervention had greater movement skill proficiency and improved anthropometric measures (waist circumference and BMI z scores) post intervention. Three years later, intervention girls had retained their object control skill advantage. The study purpose was to assess whether at 3-year follow up a) intervention children were more physically active than controls and b) the intervention effect on anthropometrics was still present. METHODS: Children were assessed at ages 4, 5, and 8 years for anthropometric measures and locomotor and object control proficiency (Test of Gross Motor Development-2). At age 8, children were also assessed for moderate to vigorous physical activity (MVPA) (using accelerometry). Several general linear models were run, the first with MVPA as the outcome, intervention/control, anthropometrics, object control and locomotor scores as predictors, and age and sex as covariates. The second and third models were similar, except baseline to follow-up anthropometric differences were the outcome. RESULTS: Overall follow-up rate was 29% (163/560), with 111 children having complete data. There were no intervention control differences in either MVPA or anthropometrics. CONCLUSION: Increased skill competence did not translate to increased physical activity.

Prevalence and correlates of low fundamental movement skill competency in children.

OBJECTIVE: To describe the demographic and health-related characteristics of school-aged children with low competency in fundamental movement skills (FMS). METHODS: Cross-sectional representative school-based survey of Australian elementary and high school students (n = 6917) conducted in 2010. Trained field staff measured students' height, weight, and assessed FMS and cardiorespiratory endurance (fitness). Information on students' demographics and physical activity was collected by questionnaire. RESULTS: Overall, the prevalence of students with low motor skill competency was high. Girls with low socioeconomic status (SES) were twice as likely to be less competent in locomotor skills compared with high SES peers. Among boys, there was a strong association between low competency in FMS and the likelihood of being from non-English-speaking cultural backgrounds. There was a clear and consistent association between low competency in FMS and inadequate cardiorespiratory fitness. For boys, there was a clear association between low competency in object-control skills and not meeting physical activity recommendations. Conversely, the odds of being inactive were double among girls who had low competency in locomotor skills. CONCLUSIONS: Low competency in FMS is strongly associated with lower cardiorespiratory fitness and physical activity levels in children and adolescents. The characteristics of students with competency in FMS differ by gender and skills types and show that interventions need to target girls from low SES backgrounds and boys from non-English-speaking cultural backgrounds. The high prevalence of low competency in FMS among Grade 4 students indicates that FMS interventions need to start during the preschool and early school years.

Reduction in staff smoking rates in North Coast Area Health Service, NSW, following the introduction of a smoke-free workplace policy.

AIM: To evaluate changes in staff smoking rates following the implementation of Smoke Free Health Care, an innovative, change-management process that introduced a smoke-free workplace policy in the North Coast Area Health Service of NSW. METHODS: Survey questionnaires were sent to all staff before and after the introduction of the policy. Return rates were 17.3% (690/3988) in 1999 and 25.4% (2012/7921) in 2007. Chi-square tests and multivariate logistic regression analysis were used to determine differences. RESULTS: Staff smoking rates decreased significantly from 22.3% to 11.8% (p<0.0001). Smoking rates in 1999 were not significantly different to the state population's (22.3% and 24.1%, p=0.3), but were significantly different in 2007 (11.8% and 20.1%, p<0.0001). Over a quarter (27.6%) of staff who smoked when implementation began quit smoking; more than twice the rate before implementation (12%, p<0.0001). CONCLUSION: These changes in staff smoking rates indicate the effectiveness of a comprehensive change-management approach to implementing smoke-free workplace policy.