What helped and hindered implementation of an intervention package to reduce smoking in pregnancy: process evaluation guided by normalization process theory.

BACKGROUND: Smoking in pregnancy causes harm to mother and baby. Despite evidence from trials of what helps women quit, implementation in the real world has been hard to achieve. An evidence-based intervention, babyClear©, involving staff training, universal carbon monoxide monitoring, opt-out referral to smoking cessation services, enhanced follow-up protocols and a risk perception tool was introduced across North East England. This paper presents the results of the qualitative analyses, reporting acceptability of the system changes to staff, as well as aids and hindrances to implementation and normalization of this complex intervention. METHODS: Process evaluation was used to complement an effectiveness study. Interviews with maternity and smoking cessation services staff and observations of training were undertaken. Normalization Process Theory (NPT) was used to frame the interview guides and analysis. NPT is an empirically-derived theory, developed by sociologists, that uses four concepts to understand the process of routinising new practices. RESULTS: Staff interviews took place across eight National Health Service trusts at a time of widespread restructuring in smoking cessation services. Principally interviewees worked in maternity (n = 63) and smoking cessation services (n = 35). Five main themes, identified inductively, influenced the implementation: 1) initial preparedness of the organisations; 2) staff training; 3) managing partnership working; 4) resources; 5) review and planning for sustainability. CONCLUSIONS: NPT was used to show that the babyClear© package was acceptable to staff in a range of organisations. Illustrated in Themes 1, 2 & 3, staff welcomed ways to approach pregnant women about their smoking, without damaging their professional relationship with them. Predicated on producing individual behaviour change in women, the intervention does this largely through reorganising and standardising healthcare systems that are required to implement best practice guidelines. Changing organisational systems requires belief and commitment from staff, so that they set up and maintain practical adjustments to their practice and are reflective about adapting themselves and the work context as new challenges are encountered. The ongoing challenge is to identify and maintain the elements of the intervention package which are essential for its effectiveness and how to tailor them to local circumstances and resources without compromising its core ingredients.

Does domiciliary welfare rights advice improve health-related quality of life in independent-living, socio-economically disadvantaged people aged ≥60 years? Randomised controlled trial, economic and process evaluations in the North East of England.

BACKGROUND: There are major socio-economic gradients in health that could be influenced by increasing personal resources. Welfare rights advice can enhance resources but has not been rigorously evaluated for health-related impacts. METHODS: Randomised, wait-list controlled trial with individual allocation, stratified by general practice, of welfare rights advice and assistance with benefit entitlements, delivered in participants' homes by trained advisors. Control was usual care. Participants were volunteers sampled from among all those aged ≥60 years registered with general practices in socio-economically deprived areas of north east England. Outcomes at 24 months were: CASP-19 score (primary), a measure of health-related quality of life; changes in income, social and physical function, and cost-effectiveness (secondary). Intention to treat analysis compared outcomes using multiple regression, with adjustment for stratification and key covariates. Qualitative interviews with purposive samples from both trial arms were thematically analysed. FINDINGS: Of 3912 individuals approached, 755 consented and were randomised (381 Intervention, 374 Control). Results refer to outcomes at 24 months, with data available on 562 (74.4%) participants. Intervention was received as intended by 335 (88%), with 84 (22%) awarded additional benefit entitlements; 46 did not receive any welfare rights advice, and none of these were awarded additional benefits. Mean CASP-19 scores were 42.9 (Intervention) and 42.4 (Control) (adjusted mean difference 0.3 [95%CI -0.8, 1.5]). There were no significant differences in secondary outcomes except Intervention participants reported receiving more care at home at 24m (53.7 (Intervention) vs 42.0 (Control) hours/week (adjusted mean difference 26.3 [95%CIs 0.8, 56.1]). Exploratory analyses did not support an intervention effect and economic evaluation suggested the intervention was unlikely to be cost-effective. Qualitative data from 50 interviews suggested there were improvements in quality of life among those receiving additional benefits. CONCLUSIONS: We found no effects on health outcomes; fewer participants than anticipated received additional benefit entitlements, and participants were more affluent than expected. Our findings do not support delivery of domiciliary welfare rights advice to achieve the health outcomes assessed in this population. However, better intervention targeting may reveal worthwhile health impacts.

Anticipated survival and health behaviours in older English adults: cross sectional and longitudinal analysis of the English Longitudinal Study of Ageing.

BACKGROUND: Individuals may make a rational decision not to engage in healthy behaviours based on their assessment of the benefits of such behaviours to them, compared to other uncontrollable threats to their health. Anticipated survival is one marker of perceived uncontrollable threats to health. We hypothesised that greater anticipated survival: a) is cross-sectionally associated with healthier patterns of behaviours; b) increases the probability that behaviours will be healthier at follow up than at baseline; and c) decreases the probability that behaviours will be 'less healthy' at follow than at baseline. METHODS: Data from waves 1 and 5 of the English Longitudinal Survey of Ageing provided 8 years of follow up. Perceptions of uncontrollable threats to health at baseline were measured using anticipated survival. Health behaviours considered were self-reported cigarette smoking, physical activity level, and frequency of alcohol consumption. A wide range of socio-economic, demographic, and health variables were adjusted for. RESULTS: Greater anticipated survival was cross-sectionally associated with lower likelihood of smoking, and higher physical activity levels, but was not associated with alcohol consumption. Lower anticipated survival was associated with decreased probability of adopting healthier patterns of physical activity, and increased probability of becoming a smoker at follow up. There were no associations between anticipated survival and change in alcohol consumption. CONCLUSIONS: Our hypotheses were partially confirmed, though associations were inconsistent across behaviours and absent for alcohol consumption. Individual assessments of uncontrollable threats to health may be an important determinant of smoking and physical activity.

Socioeconomic position and the association between anticipated and actual survival in older English adults.

BACKGROUND: Socioeconomic disadvantage may cause individuals to have lower expectations of longevity and not engage in healthy behaviours because they judge the long-term health benefits of these to be minimal. We explored demographic, health behaviour, health and socioeconomic correlates of subjectively estimated lifespan ('anticipated survival'); the ability of anticipated survival to predict actual survival; and whether the predictive ability of anticipated survival differed by other variables, particularly socioeconomic position. METHODS: Data were from wave 1 of the English Longitudinal Study of Ageing. Anticipated survival for up to 25 years was measured on a scale of 0-100. Actual survival was measured over a mean of 6 years, and socioeconomic position using education, household income, occupational class and area deprivation. RESULTS: Of 10 768 participants, 2255 (21%) died during follow-up. Anticipated survival was positively associated with socioeconomic position, and was greater in women, younger individuals, non-smokers and those who were not widowed, consumed more alcohol, were more physically active, and reported better physical and mental health. After full adjustment, anticipated survival remained positively associated with actual survival. Those reporting low anticipated survival were more likely to die over time than those reporting moderate anticipated survival (HR (95% CIs 1.11 (1.00 to 1.23). The relationship differed significantly by income and age, being strongest in younger individuals and those with higher household income. CONCLUSIONS: Anticipated survival varied with other variables as expected and reflected actual survival. Younger individuals and those with higher household income were better able to identify subtle differences associated with actual survival.

Socioeconomic and behavioural risk factors for adverse winter health and social outcomes in economically developed countries: a systematic review of quantitative observational studies.

BACKGROUND: Mortality and morbidity rates are often highest during the winter period, particularly in countries with milder climates. A growing body of research has identified potential socioeconomic, housing and behavioural mediators of cold weather-related adverse health and social outcomes, but an inclusive systematic review of this literature has yet to be performed. METHODS: A systematic review, with narrative synthesis, of observational research published in English between 2001 and 2011, which quantified associations between socioeconomic, housing or behavioural factors and cold weather-related adverse health or social outcomes. RESULTS: Thirty-three studies met the inclusion criteria. Average study quality was not high. Most studies failed to control for all relevant confounding factors, or to conduct research over a long enough period to ascertain causality. Low income, housing conditions and composite fuel poverty measures were most consistently associated with cold weather-related adverse health or social outcomes. CONCLUSIONS: This review identified socioeconomic, housing and behavioural factors associated with a range of cold weather-related adverse health or social outcomes. Only tentative conclusions can be drawn due to the limitations of existing research. More robust studies are needed to address the methodological issues identified and uncover causal associations. A review of qualitative and intervention studies would help to inform policies to reduce the adverse health and social impacts of cold weather.

Dynamics of human mortality.

Historical human mortality curves display five phases, differing in dimensions with population, time and circumstance. Existing explanatory models describe some but not all of these, and modelling of entire curves has hitherto necessitated an assumption of multiple distributions. A new distribution, shown previously to describe survival in experimental animals, postulates empirically that net mortality risk comprises two components described as 'redundancy decay' and 'interactive risk'. The former is proposed effectively to set a 'program' for the increase of mortality risk with age, and may be a better measure of the 'rate of ageing' which has previously been assumed to determine the slope of semi-logarithmic mortality curves. Entire human mortality curves are shown here to be compatible with this single distribution given the assumption that individuals vary only with respect to the interactive risk parameter (k). Historical Swedish cohort data are modelled here exclusively through changes in k values, clustered increasingly toward the higher end of their range, while redundancy values are held constant. This pattern is compatible with the hypothesis that historical changes in human mortality may be explained purely in terms of interactive risks and without changes in the underlying pattern or rate of ageing.

The natural distribution of survival.

Great similarities in survival patterns permit the Gompertz and other established equations to describe parts of mortality curves in various species. These patterns appear non-random and invite inference of biological meaning, though no unifying explanation is agreed. Under the theory described here, linear decline of an initial quantity of species or strain-specific redundant reserve interacts with extrinsic hazards via a 'nested binomial' model, which is presented both in a simple, four parameter form, and a more complex form that incorporates inter-individual and inter-functional biological variation. This approach demonstrates exponential rises in mortality, late-life deceleration and Strehler-Mildvan correlation. Biological variation within the complex model, specifically in the redundancy decay rate parameter, is shown to generate mortality plateaux, while outlier phenotypes produce mortality decelerations, supporting inter-individual heterogeneity as the cause of these phenomena. The model is robust to large variations in organism complexity, and to broad intra-population hazard variation. Specific parameters appear analogous to observed elements of ageing, and a central role for redundancy depletion provides a context for longevity genes and rapid evolution of increased lifespan. This approach offers a unifying model for a great variety of ageing phenomena across a wide range of species.

Postponement of postmenopausal mortality acceleration in low-mortality populations.

Mortality analyses commonly disregard postmenopausal acceleration. This study examined period log mortality in World Health Organization (WHO) data for 34 low-mortality countries in 2000, demonstrating significant gradient increases for women (33/34 countries) and men (22/34), from a later age than previously reported, dividing the postmenopausal period into phases. "Break points" were identified as intersects of lines of best fit to these and the same approach was used in analysis of Human Mortality Database data for 19 countries. There has been an upward migration of about 10 years in female age at break point since 1850. Male data flipped from mortality acceleration to deceleration and back in the late 20th century with no apparent shift in break point. Altered age at mortality acceleration appears genuine, gender-specific, and internationally consistent. Its timing prompts the hypothesis that it may relate to falling fertility.

When does human ageing begin?

Through much of the 20th century, the low point of human mortality was seen at 12-13 years of age. Its stability and timing have been accorded significance in terms of evolution, maximal fitness and the onset of ageing. The nadir of mortality in developed nations now lies at 5-9 years, significantly predating fertility at a mean of 12-13. This differential fall in mortality has resulted in England and Wales primarily but not exclusively from reductions in accidents and deaths from congenital anomalies. The assumption that the nadir of mortality, onset of fertility and a putative intrinsic point of maximal biological fitness are synchronous is disproved by this shift. In this paper the logic of inferring an individual modal pattern of ageing from mean population behaviour is questioned, and the plausibility of the belief that ageing starts at or after fertility is examined. Biological ageing, whether seen as 'wear and tear', programmed change, or cumulative stochastic damage appears to commence at or before conception. Drawing a distinction between 'intrinsic' and 'extrinsic' mortality makes less sense in early than in late life, but indicators of 'intrinsic' diseases are also present from well before fertility. Similarly, measures of fitness other than mortality risk may also be argued to diminish from before birth.

Mortality spike at New Year but not Christmas in North East England.

Mortality in the USA has been shown to spike on Christmas and New Year's Day. No comparable analyses are available for European data despite recognised seasonal mortality variations. Deaths for 1986-2000 were analysed by date for Newcastle and North Tyneside (NNT) to examine the Christmas period and the weeks surrounding Easter. A spike in mortality attributable to increases in cardiac and respiratory deaths was seen on New Year's Day but not on Christmas Day. No disturbance of trend was seen at Easter. The causes of the 'holiday phenomenon' are not understood, but absence of a Christmas spike in NNT may indicate that it is preventable.