Models of care in secure services for people with intellectual and developmental disability: Implementing the Walkway to Wellness.

BACKGROUND: Changes to policy around inpatient services for people with intellectual and developmental disability (IDD) who offend, have led to a need for services to reconsider their models of care. This has led to calls for more tailored, patient-centred care models, with less reliance solely on offence-related treatment programmes which can be unsuitable for a growing proportion of patients with more complex cognitive and behavioural difficulties. In response, the Walkway to Wellness (W2W) was developed at one National Health Service Trust providing secure services to people with IDD, with the intention of delivering a more collaborative, co-produced and goal-oriented care model that was better understood by staff and patient stakeholders. AIMS: To evaluate the implementation of the W2W using Normalisation Process Theory (NPT), an evidence-based theoretical approach is used across a number of health settings. METHODS: Staff were invited to complete a short questionnaire, using the NPT informed Normalisation Measure Development questionnaire, at two time points along the implementation process. Patients were invited to complete a simplified questionnaire. Both groups were asked for their views on the W2W and the process of its implementation. RESULTS: Although the W2W was more familiar to staff at the second time point, scores on the four NPT constructs showed a trend for it being less embedded in practice, with significant results concerning the ongoing appraisal of the new model. Patient views were mixed; some saw the benefit of more goal-oriented processes, but others considered it an additional chore hindering their own perceived goals. CONCLUSION: Early involvement of all stakeholders is required to enhance the understanding of changes to models of care. Live feedback should be used to refine and revise the model to meet the needs of patients, carers and staff members.

A hypothesis: King Henry VIII's (1491-1547) personality change: A case of lead poisoning?

Henry VIII (1491-1547) became King of England in 1509. He started out as a good monarch, sensible, reasonable and pleasant, but later his behaviour changed drastically. He became irascible, intolerant, violent and tyrannical. In January 1536, Henry had a serious jousting accident and was unconscious for 2 h. It is generally believed that this accident played a major role in his personality change. Letters of that time, however, indicate that the change began insidiously in 1534 and became most drastic in 1535, a year before the accident. Henry had suffered from leg ulcers before and after the accident and had been constantly treated for them for many years. Sloane MS1047, now in the British Library in London, contains the prescriptions for the medications used to treat these ulcers. Many of the medications contain a high proportion of lead in various forms. Lead can be absorbed through skin, especially damaged skin. Absorbed lead can affect the brain, causing psychiatric problems, especially those associated with violence. The author presents a hypothesis that absorbed lead from his medications might have been a major factor in King Henry's personality change.

George Cheyne (1671 or 73-1743): 18th-century physician.

George Cheyne was a well-known physician with a practice in Bath and London. He was a fat, jovial Scotsman weighing 32 stone at one time and with a great sense of humour who could be classed as one of the characters of the period. His health suffered seriously from eating and drinking too much in taverns with his 'bottle companions' when young, and he spent the rest of his life writing books for the public to help them avoid the problems he had experienced, with a particular emphasis on diet and nervous disorders. His book entitled An Essay on Health and Long Life had particular success. Although often lampooned, he had many famous patients including Beau Nash, Samuel Richardson, The Countess of Huntingdon and Catherine Walpole, the eldest daughter of the Prime Minister Robert Walpole. He was a skilled and caring doctor and health educator, and has been said to have established the agenda for psychiatric epidemiology.

Catherine Walpole (1703-22), an 18th-century teenaged patient: a case study from the letters of the physician George Cheyne (1671 or 73-1743).

In 1720 Catherine Walpole the 16-year-old eldest daughter of Robert Walpole, later to become Prime Minister, became very ill. She was unable to eat, fainted, took fits frequently, and had a persistent pain and swelling in her side. Sir Hans Sloane, the Walpole's doctor, referred her to Dr Cheyne in Bath because he specialized in dietary problems and nervous diseases. Cheyne kept in regular touch with Sir Hans by letter and this correspondence tells the story of Catherine's treatment from her first referral to Cheyne to her death in 1722. The contents and purposes of treatments he used are identifiable in dispensatories of the period. The letters reflect Cheyne's medical skills and knowledge as well as his sympathetic personality. Catherine's family loyalties, personal concerns and personality also emerge as the correspondence progresses. The limitations of 18th-century diagnosis and treatments available are clear but Cheyne is always concerned with Catherine's quality of life, even when he becomes aware that he cannot cure her.

Mediated, moderated and direct effects of country of residence, age, and gender on the cognitive and social determinants of adolescent smoking in Spain and the UK: a cross-sectional study.

BACKGROUND: European trans-national adolescent smoking prevention interventions based on social influences approaches have had limited success. The attitudes-social influences-efficacy (ASE) model is a social cognition model that states smoking behaviour is determined by smoking intention which, in turn, is predicted by seven ASE determinants; disadvantages, advantages, social acceptance, social norms, modelling, perceived pressure, self-efficacy. Distal factors such as country of residence, age and gender are external to the model. The ASE model is, thus, closely related to the Theory of Planned Behaviour. This study assessed the utility of the ASE model using cross-sectional data from Spanish and UK adolescents. METHODS: In 1997, questionnaires were simultaneously administered to Spanish (n = 3716) and UK adolescents (n = 3715) who were considered at high risk of smoking. Participants' age, gender, smoking intentions and ASE determinant scores were identified and linear regression analysis was used to examine the mediated, moderated and direct effects of country of residence, age and gender on participants' smoking intentions. RESULTS: All UK participants were aged 12 or 13 and most Spanish participants were aged between 12 and 14 (range 12-16 years). Amongst 12 and 13 year olds, regular smoking was more common in Spain. Almost half the participants were female (47.2% in Spain; 49.9% in the UK). Gender did not vary significantly according to age. The distribution of ASE determinant scores varied by country and predicted intention. The influence of each ASE determinant on intention was moderated by country. Country had a large direct influence on intention (1.72 points on a 7 point scale) but the effects of age and gender were mediated by the ASE determinants. The findings suggest resisting peer pressure interventions could potentially influence smoking amongst UK adolescents but not Spanish adolescents. Interventions that promote self-efficacy, on the other hand, would possibly have a greater influence on smoking amongst Spanish adolescents. CONCLUSION: The ASE model may not capture important cultural factors related to adolescent smoking and the relative contribution of particular ASE determinants to adolescent smoking intentions may differ between countries. Future European trans-national adolescent smoking prevention programmes may benefit from greater understanding of country-level cultural norms.

Health risks information reaches secondary school smokers.

This cross-sectional study aimed to assess smoking prevention and cessation education delivered as part of the UK National Curriculum and to evaluate the relative effectiveness of health, social influence and other/non-health components. In all, 1789 students aged 11-15 from 12 secondary schools completed online surveys assessing smoking status, factors known to be related to smoking and experience of smoking education. A total of 1421 of 1722 (83%) students remembered some school-based education. Of these, 803 (57%) said that the lessons changed their ideas about smoking. Multinomial logistic regression was used to assess whether lesson recall was associated with smoking status in a model adjusting for age, gender, ethnicity, family and best friend smoking status, socioeconomic status, and school. Quitters were more likely than smokers to report having changed their ideas about smoking as a result of a lesson (OR 5.78, 95% CI 2.44-13.72). The relative effectiveness of 16 lesson themes was assessed. Significantly more students changed their ideas about smoking as a result of 'health' compared with 'social influence' (chi(2) (1) 124.0, P < 0.001) or 'other/non-health' (chi(2) (1) 63.16, P < 0.001) topics. Mouth cancer was the most effective health topic and may provide a suitable model for both smoking and risky drinking prevention.

An example of health education in the early 17th century: Naturall and artificial Directions for Health by William Vaughan.

In 1600, William Vaughan, a Doctor of Civil Laws, published the first edition of his health education manual entitled Naturall and artificial Directions for Health. In all, seven editions appeared over the next 33 years. Changes were made to the title and contents, but the same six general areas were covered in each, i.e. (1) Air, fire and water, (2) Food and drink, (3) Sleep and early rising, (4) Evacuations, (5) Infirmities and death, and (6) Restoration of health. Although Vaughan was writing before the scientific revolution, and had to base his advice on the current theories of the four humours, miasma, stars and the supernatural, research over the intervening four centuries has proven many of his messages to be correct, e.g. clean air and water, a balanced diet, olive oil, low animal fat, red wine, fibre, exercise, and avoiding tobacco use, to mention but a few. In Vaughan's day, these messages were new to many readers and the method of health education used was simply to present the information for people to act on. Behavioural research carried out in the last century has changed the approach to health education by involving decision-making processes, self-efficacy building and social support.

Tobacco or health 1602: an Elizabethan doctor speaks.

A few years before the death of Queen Elizabeth I, a booklet entitled Work for Chimny-Sweepers or A Warning for Tabacconists [sic], was published. Written by a doctor who called himself Philaretes, it was the first publication to present the health risks of tobacco use. Using continuum content analysis, which follows each of Philaretes's main messages over the subsequent four centuries, this paper sets his publication in the historical context of the medical and social frame of reference in which it was produced, and charts the development of each theme in later scientific research. In the setting of contemporary Tudor medical theory, based on 'the humours', Philaretes discussed many of the health risks that later research has proven to be true. In common with many early attempts at health education, the principles of Philaretes's approach appear to be what were later to be called the Health Belief Model and the KAP formula. By providing information about serious personal health risks and, thus, increasing the readers' knowledge, he hoped to change their attitude and consequently their behaviour. Overshadowed by King James I's much less scientific Counterblaste to Tobacco, Philaretes's publication deserves more credit than it has been given.

Impact of cigarette advertising on smoking behaviour in Spanish adolescents as measured using recognition of billboard advertising.

BACKGROUND: Cross-sectional studies provide empirical support for associations between advertising and adolescent smoking. The aim of this study was to investigate the relationship between Spanish adolescent smoking behaviour and prior awareness of cigarette advertisements on billboards, using a prospective design. METHODS: 3,664 Spanish children aged 13 and 14 years filled in self-completion questionnaires at baseline, and 6, 12, and 18 months later (cohort study). Slides of three advertisements were projected at baseline. A multivariate logistic regression analysis was carried out to detect possible association between number of identified tobacco advertisements brands at baseline and smoking status along time, controlling ASE Model smoking determinants, smoking prevention interventions, age, gender and socio-economic status. RESULTS: The more advertisements identified at baseline, the greater was the risk of being a smoker (p<0.0001). Final percentages of smokers were 15.8%, 16.3%, 19.3%, and 32.6%, respectively, for zero, one, two and three advertisements recognized. When confounders were controlled, the probability of being a smoker increased with the number of advertisements identified [OR 1.26 (95% CI: 1.09-1.46) after 6 months, OR 1.18 (95% CI: 1.03-1.35) after 12 months and 1.15 (95% CI: 1.02-1.30)] after 18 months. It is possible the association would have been even greater if there had not been a differential loss of smokers from the sample. CONCLUSION: Increased awareness of cigarette advertising was associated with a higher smoking incidence and an increased risk of Spanish children becoming smokers. It is, therefore, imperative that cigarette advertising should be banned as a matter of urgency.

What determines future smoking intentions of 12- to 13-year-old UK African-Caribbean, Indian, Pakistani and white young people?

It is important to know when designing adolescent smoking interventions how ethnicity and gender influence intention. This paper reports an investigation into how ethnicity influences the smoking intentions of disadvantaged UK African-Caribbean (n = 275), Indian (n = 397), Pakistani (n = 687) and white (n = 1792) 12-13 year olds. The Attitudes-Social influences-Efficacy (ASE) model underpinned the study. It states that ASE determinants (advantages, disadvantages, social acceptance, social norms, modelling, perceived pressure and self-efficacy) directly influence behavioural intention. External factors (country, ethnicity and gender) indirectly influence intention by influencing ASE determinants. ASE determinant scores and future smoking intentions were measured. Linear regression analyses showed that smoking intention varied by ethnicity and gender. Differences in ASE scores largely explained these variations. Ethnicity and gender did not modify the predictive effects of equivalent ASE determinant scores on intention. Being a white boy had a small independent direct influence on intention, which was ascribed to affective beliefs underpinning fitness and sporting prowess. Otherwise, ethnicity had no independent direct effects on intention. Culturally appropriate interventions that aim to change cognitions underpinning ASE determinants and, thus, ASE scores would, consequently, be expected to be equally effective amongst disadvantaged UK African-Caribbean, Indian, Pakistani and white adolescents.

The European Smoking Prevention Framework Approach (EFSA): an example of integral prevention.

A smoking prevention project in six European countries (European Smoking prevention Framework Approach) was developed, featuring activities for adolescents, schools and parents, including out-of-school activities. Consensus meetings resulted in agreement between the countries on goals, objectives and theoretical methods. Countries' specific objectives were also included. National diversities required country-specific methods to realize the goals and objectives. The community intervention trial was used as the research design. Since interventions took place at the community level, communities or regions were allocated at random to the experimental or control conditions. Complete randomization was achieved in four countries. At baseline, smoking prevalence among 23 125 adolescents at the start of the project was 5.6% for regular smoking and 4.0% for daily smoking. Smoking prevalence rates were higher among girls than boys in all countries as far as weekly smoking was concerned. Process evaluations revealed that the project's ambitions were high, but were limited by various constraints including time and delays in receiving funds. Future smoking prevention projects should aim to identify the effective components within the social influence approach as well as within broader approaches and on reaching sustained effects.

Current action for skin cancer risk reduction in English schools: pupils' behaviour in relation to sunburn.

In a random sample of schools distributed throughout all areas of England, 2703 primary school pupils from 46 schools and 2692 secondary school pupils from 32 schools were surveyed regarding behaviour in the sun, and opinions and experience of sunburn. Seventy percent (1879) of primary and 36.5% (982) of secondary pupils recalled hearing about protecting themselves from the sun at school. Primary school pupils who recalled they were told to 'stay in the shade' were more likely say they did so; 27.3% (739) of primary and 20.7% (556) of secondary school pupils reported getting sunburnt; and 53.2% (393/739) primary school pupils and 52.5% (292/556) secondary school pupils reporting sunburn said their sunburn peeled. The most common time both primary and secondary pupils said they got sunburnt at school was at lunchtime (mid-day break); the next most common time was during sports day. Pupils saying they did not protect their skin because they wanted a tan were more likely to report sunburn (41.7% primary and 29.5% secondary) than those giving other reasons. Primary school pupils who said they used sun screen frequently (285/847) were more likely than 'never users' (178/813) to report sunburn, as were secondary school pupils (53/192 and 264/1565 for frequent and 'never users', respectively). Dark- and light-skinned pupils at primary school (27.3 and 27.4%, respectively) were equally likely to say they had been sunburnt. At secondary school, only 10.6% of dark-skinned compared with 22.3% of light-skinned pupils reported sunburn. The last two findings might be related to cultural behaviours and are discussed later. Pupils of all ages need encouragement to protect their skin at mid-day break, to use sunscreens correctly and be aware of alternative sun-protection methods. Education is needed which challenges the notion that a 'tan is beautiful' and uses social teaching methods to empower pupils to carry out sun protection in real life.