Dataset Information

Successful implementation of a wellness and tobacco cessation curriculum in psychosocial rehabilitation clubhouses.

ABSTRACT:

Background

Tobacco remains a seemingly intractable problem for individuals living with severe and persistent mental illness. This study evaluated the implementation, technical assistance, and perceived impact of a model curriculum ("Learning About Healthy Living") to promote wellness and motivation to quit tobacco use in psychosocial rehabilitation clubhouses.

Methods

We used semi-structured interviews (n = 9) with clubhouse staff (n = 12) and a survey of participating clubhouse members (n = 271) in nine clubhouses.

Results

Fifty-eight percent of clubhouse participants completed surveys. Results showed tobacco users open to tobacco-free policies (62%) and perceiving more discussions about quitting tobacco with healthcare providers (69%). Analyses of staff interviews and member surveys revealed four key themes: (1) the curriculum was successfully implemented and appreciated; (2) technical assistance kept implementation on track; (3) adding wellness content and interactive components should enhance the curriculum; and, (4) the curriculum advanced other healthful policies and practices.

Conclusions

Mental health settings are important locations for implementing programs to address tobacco use. In this real-world implementation of a model curriculum in psychosocial rehabilitation clubhouses, the curriculum tested well, was feasible and well-received, and suggests potential impact on tobacco use outcomes. Revision, dissemination, and a randomized controlled trial evaluation of the model curriculum should now occur.

SUBMITTER: Lee JG

PROVIDER: S-EPMC3184072 | biostudies-literature | 2011 Sep

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Successful implementation of a wellness and tobacco cessation curriculum in psychosocial rehabilitation clubhouses.

Lee Joseph G L JG Ranney Leah M LM Goldstein Adam O AO McCullough Anna A Fulton-Smith Sterling M SM Collins Nicole O NO

BMC public health 20110914

<h4>Background</h4>Tobacco remains a seemingly intractable problem for individuals living with severe and persistent mental illness. This study evaluated the implementation, technical assistance, and perceived impact of a model curriculum ("Learning About Healthy Living") to promote wellness and motivation to quit tobacco use in psychosocial rehabilitation clubhouses.<h4>Methods</h4>We used semi-structured interviews (n = 9) with clubhouse staff (n = 12) and a survey of participating clubhouse m ...[more]

PMID: 21917179

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Project description:BackgroundTobacco use adversely affects oral health. Clinical guidelines recommend that dental providers promote tobacco abstinence and provide patients who use tobacco with brief tobacco use cessation counselling. Research shows that these guidelines are seldom implemented, however. To improve guideline adherence and to develop effective interventions, it is essential to understand provider behaviour and challenges to implementation. This study aimed to develop a theoretically informed measure for assessing among dental providers implementation difficulties related to tobacco use prevention and cessation (TUPAC) counselling guidelines, to evaluate those difficulties among a sample of dental providers, and to investigate a possible underlying structure of applied theoretical domains.MethodsA 35-item questionnaire was developed based on key theoretical domains relevant to the implementation behaviours of healthcare providers. Specific items were drawn mostly from the literature on TUPAC counselling studies of healthcare providers. The data were collected from dentists (n = 73) and dental hygienists (n = 22) in 36 dental clinics in Finland using a web-based survey. Of 95 providers, 73 participated (76.8%). We used Cronbach's alpha to ascertain the internal consistency of the questionnaire. Mean domain scores were calculated to assess different aspects of implementation difficulties and exploratory factor analysis to assess the theoretical domain structure. The authors agreed on the labels assigned to the factors on the basis of their component domains and the broader behavioural and theoretical literature.ResultsInternal consistency values for theoretical domains varied from 0.50 ('emotion') to 0.71 ('environmental context and resources'). The domain environmental context and resources had the lowest mean score (21.3%; 95% confidence interval [CI], 17.2 to 25.4) and was identified as a potential implementation difficulty. The domain emotion provided the highest mean score (60%; 95% CI, 55.0 to 65.0). Three factors were extracted that explain 70.8% of the variance: motivation (47.6% of variance, α = 0.86), capability (13.3% of variance, α = 0.83), and opportunity (10.0% of variance, α = 0.71).ConclusionsThis study demonstrated a theoretically informed approach to identifying possible implementation difficulties in TUPAC counselling among dental providers. This approach provides a method for moving from diagnosing implementation difficulties to designing and evaluating interventions.

Project description:BackgroundAcross the United States, substance use disorder (SUD) treatment programs vary in terms of tobacco-related policies and cessation services offered. Implementation of tobacco-related policies within this setting can face several barriers. Little is known about how program leadership anticipate such barriers at the pre-implementation phase. This study used the Consolidated Framework for Implementation Research (CFIR) during the pre-implementation stage to identify factors that may influence the implementation stage of tobacco-related cessation policies and services in residential SUD programs.MethodsWe conducted semi-structured qualitative interviews with sixteen residential treatment program directors in California. The analysis was guided by a deductive approach using CFIR domains and constructs to develop codes and identify themes. ATLAS.ti software was used to facilitate thematic analysis of interview transcripts.FindingsThemes that arose as anticipated facilitators for implementation included the relative advantage of the intervention vs. current practice, external policies/incentives to support tobacco-related policy, program directors' strong commitment and high self-efficacy to incorporate cessation into SUD treatment, and recognizing the importance of planning and engaging opinion leaders. Potential barriers included the SUD recovery culture, low stakeholder engagement, organizational culture, lack of workforce expertise, and lack of reimbursement for smoking cessation services.ConclusionTo support successful implementation of tobacco-related organizational change interventions, staff and clients of residential SUD programs require extensive education about the effectiveness of evidence-based medications and behavioral therapies for treating tobacco dependence. Publicly funded SUD treatment programs should receive support to address tobacco dependence among their clients through expanded reimbursement for tobacco cessation services.

Project description:BackgroundClinical decision support (CDS) tools in electronic health records (EHRs) are often used as core strategies to support quality improvement programs in the clinical setting. Monitoring the impact (intended and unintended) of these tools is crucial for program evaluation and adaptation. Existing approaches for monitoring typically rely on health care providers' self-reports or direct observation of clinical workflows, which require substantial data collection efforts and are prone to reporting bias.ObjectiveThis study aims to develop a novel monitoring method leveraging EHR activity data and demonstrate its use in monitoring the CDS tools implemented by a tobacco cessation program sponsored by the National Cancer Institute's Cancer Center Cessation Initiative (C3I).MethodsWe developed EHR-based metrics to monitor the implementation of two CDS tools: (1) a screening alert reminding clinic staff to complete the smoking assessment and (2) a support alert prompting health care providers to discuss support and treatment options, including referral to a cessation clinic. Using EHR activity data, we measured the completion (encounter-level alert completion rate) and burden (the number of times an alert was fired before completion and time spent handling the alert) of the CDS tools. We report metrics tracked for 12 months post implementation, comparing 7 cancer clinics (2 clinics implemented the screening alert and 5 implemented both alerts) within a C3I center, and identify areas to improve alert design and adoption.ResultsThe screening alert fired in 5121 encounters during the 12 months post implementation. The encounter-level alert completion rate (clinic staff acknowledged completion of screening in EHR: 0.55; clinic staff completed EHR documentation of screening results: 0.32) remained stable over time but varied considerably across clinics. The support alert fired in 1074 encounters during the 12 months. Providers acted upon (ie, not postponed) the support alert in 87.3% (n=938) of encounters, identified a patient ready to quit in 12% (n=129) of encounters, and ordered a referral to the cessation clinic in 2% (n=22) of encounters. With respect to alert burden, on average, both alerts fired over 2 times (screening alert: 2.7; support alert: 2.1) before completion; time spent postponing the screening alert was similar to completing (52 vs 53 seconds) the alert, and time spent postponing the support alert was more than completing (67 vs 50 seconds) the alert per encounter. These findings inform four areas where the alert design and use can be improved: (1) improving alert adoption and completion through local adaptation, (2) improving support alert efficacy by additional strategies including training in provider-patient communication, (3) improving the accuracy of tracking for alert completion, and (4) balancing alert efficacy with the burden.ConclusionsEHR activity metrics were able to monitor the success and burden of tobacco cessation alerts, allowing for a more nuanced understanding of potential trade-offs associated with alert implementation. These metrics can be used to guide implementation adaptation and are scalable across diverse settings.

Project description:By 2030, 80 % of the annual 8.3 million deaths attributable to tobacco will be in low-income countries (LICs). Yet, services to support people to quit tobacco are not part of routine primary care in LICs. This study explored the challenges to implementing a behavioural support (BS) intervention to promote tobacco cessation within primary care in Nepal.The study used qualitative and quantitative methods within an action research approach in three primary health care centres (PHCCs) in two districts of Nepal. Before implementation, 21 patient interviews and two focus groups with health workers informed intervention design. Over a 6-month period, two researchers facilitated action research meetings with staff and observed implementation, recording the process and their reflections in diaries. Patients were followed up 3 months after BS to determine tobacco use (verified biochemically) and gain feedback on the intervention. A further five interviews with managers provided reflections on the process. The qualitative analysis used Normalisation Process Theory (NPT) to understand implementation.Only 2 % of out-patient appointments identified the patient as a smoker. Qualitative findings highlight patients' unwillingness to admit their smoking status and limited motivation among health workers to offer the intervention. Patient-centred skills needed for BS were new to staff, who found them challenging particularly with low-literacy patients (skill set workability). Heath workers saw cessation advice and BS as an addition to their existing workload (relational integration). While there was strong policy buy-in, operationalising this through reporting and supervision was limited (contextual integration). Of the 44 patients receiving the intervention, 27 were successfully followed up after 3 months; 37 % of these had quit (verified biochemically).Traditionally, primary health care in LICs has focused on acute care; with increasing recognition of the need for lifestyle change, health workers must develop new skills and relationships with patients. Appropriate and regular recording, reporting, supervision and clear leadership are needed if health workers are to take responsibility for smoking cessation. The consistent implementation of these health system activities is a requirement if cessation services are to be normalised within routine primary care.

Project description:The inequity in cessation resources is at the forefront of the recently enacted US smoking ban in public housing facilities. This pre-post, non-randomized pilot study assessed the feasibility of a smoking cessation program targeting smokers in Baltimore City public housing. The study implemented a four-phased, 10-week, community-based cessation program using a joint academic-housing partnership that provided on-site cessation pharmacotherapy, behavioral counseling, and psychosocial/legal services. The community-led strategy involved: (1) two-week smoking cessation training for lay health workers; (2) screening and recruitment of smokers by housing authority residential leadership; (3) four-week resident-led cessation using evidenced-based strategies along with wraparound support services; (4) formative evaluation of the intervention's acceptability and implementation. Thirty participants were recruited of which greater than one-half attended the majority of weekly cessation events. Thirty percent were able to achieve biomarker-proven cessation, as measured by a reduction in exhaled CO levels-a percentage comparable to the reported state quitline 30-day cessation rate. Despite weekly joint community-academic led-education of nicotine replacement therapy (NRT) therapies, only two participants regularly and properly used NRT transdermal patches; <20% of participants used NRT gum correctly at their first follow-up visit. Less than one-half utilized psychosocial and legal services by our community-based organization partners. Post-intervention interviews with participants noted broad approval of the ease in accessibility of the cessation intervention, but more diversification in the timing and personalization of offerings of services would have assisted in greater adoptability and participant retention. Though a reduction in smoking behaviors was not broadly observed, we elucidated modifiable social, educational, and physical features that could enhance the likelihood of smoking cessation among public housing residents.

Dataset Information

Successful implementation of a wellness and tobacco cessation curriculum in psychosocial rehabilitation clubhouses.

Background

Methods

Results

Conclusions

Publications

Successful implementation of a wellness and tobacco cessation curriculum in psychosocial rehabilitation clubhouses.

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