Child health interventions delivered by lay health workers to parents: A realist review.

There is a growing body of evidence that lay health worker (LHW) interventions are a cost-effective model of care which can improve health outcomes and reduce the burden on existing health and community services. Nonetheless, there is a dearth of information to specify which intervention characteristics contribute to their success. This realist review aimed to identify how, why and in what context UK-based LHW interventions aimed at improving child health parenting behaviours can lead to health promoting behaviour and improve child health outcomes. Results show that the 'peerness' of the LHW role gives parents a sense of equality with, and trust in, LHWs which facilitates continued engagement with interventions and sustained positive behaviour. Training and support is crucial to retention of LHWs, enhancing confidence and perceived value of the role in the context of the intervention. LHW interventions which are embedded within communities as a result of stakeholder buy-in demonstrate stable models of delivery and ease the burden on existing health and community services. In conclusion, this review found that LHW interventions can positively influence child health parenting behaviours in certain contexts and provide programme theory to inform future development of LHW interventions.

A systematic review of interventions to link families with preschool children from healthcare services to community-based support.

BACKGROUND: Supporting patients to access community-based support may be a key intervention to address the wider determinants of health. There is a lack of evidence synthesis around the most effective methods for linking individuals from health services to organizations within communities, especially those aimed at supporting families with young children. METHODS: Papers were identified from seven databases covering peer-reviewed and grey literature. The Effective Public Health Practice Project and the Critical Appraisal Skills Programme Qualitative quality appraisal tools were used to assess methodological quality. Thematic narrative data synthesis based on study quality was performed. RESULTS: Twenty-four unique publications were included in the review with a range of study designs and variable methodological quality. A broad typology of intervention processes for undertaking linking was developed defining three distinct approaches: signposting, referral and facilitation. Active processes, such as facilitation, appeared more successful at linking families to community support. CONCLUSIONS: This was the first systematic review to focus on interventions that link families with young children to community-based support organizations. It identified a typology for linking interventions, and whilst there were limitations in the quality of evidence available, it showed a tendency for more active interventions to be more effective in linking families to community support.

Evaluation of a national complex oral health improvement programme: a population data linkage cohort study in Scotland.

OBJECTIVES: Child dental caries is a global public health challenge with high prevalence and wide inequalities. A complex public health programme (Childsmile) was established. We aimed to evaluate the reach of the programme and its impact on child oral health. SETTING: Education, health and community settings, Scotland-wide. INTERVENTIONS: Childsmile (national oral health improvement programme) interventions: nursery-based fluoride varnish applications (FVAs) and supervised daily toothbrushing, community-based Dental Health Support Worker (DHSW) contacts and primary care dental practice visits-delivered to the population via a proportionate universal approach. PARTICIPANTS: 50 379 children (mean age=5.5 years, SD=0.3) attending local authority schools (2014/2015). DESIGN: Population-based individual child-level data on four Childsmile interventions linked to dental inspection survey data to form a longitudinal cohort. Logistic regression assessed intervention reach and the independent impact of each intervention on caries experience, adjusting for age, sex and area-based Scottish Index of Multiple Deprivation (SIMD). OUTCOME MEASURES: Reach of the programme is defined as the percentage of children receiving each intervention at least once by SIMD fifth. Obvious dental caries experience (presence/absence) is defined as the presence of decay (into dentine), missing (extracted) due to decay or filled deciduous teeth. RESULTS: 15 032 (29.8%) children had caries experience. The universal interventions had high population reach: nursery toothbrushing (89.1%), dental practice visits (70.5%). The targeted interventions strongly favoured children from the most deprived areas: DHSW contacts (SIMD 1: 29.5% vs SIMD 5: 7.7%), nursery FVAs (SIMD 1: 75.2% vs SIMD 5: 23.2%). Odds of caries experience were markedly lower among children participating in nursery toothbrushing (>3 years, adjusted OR (aOR)=0.60; 95% CI 0.55 to 0.66) and attending dental practice (≥6 visits, aOR=0.55; 95% CI 0.50 to 0.61). The findings were less clear for DHSW contacts. Nursery FVAs were not independently associated with caries experience. CONCLUSIONS: The universal interventions, nursery toothbrushing and regular dental practice visits were independently and most strongly associated with reduced odds of caries experience in the cohort, with nursery toothbrushing having the greatest impact among children in areas of high deprivation.

The effectiveness of Dental Health Support Workers at linking families with primary care dental practices: a population-wide data linkage cohort study.

BACKGROUND: Link workers (lay health workers, health support workers) based in the community provide additional support to individuals and families to facilitate engagement with primary care and other services and resources. This additional support aims to tackle the wider socio-economic determinants of health that lead to inequalities. To date, there is no clear evidence of the effectiveness of these programmes. This study evaluates the effectiveness of Dental Health Support Workers (DHSW) at linking targeted families with young children to primary care dental practices. The DHSW role is one component of Childsmile, the national oral health improvement programme in Scotland. METHODS: A quasi-experimental approach captured the natural variation in the rollout of the DHSW intervention across Scotland in a cohort of children born between 2010 and 2013. Survival analysis explored "time to attendance" at primary care dental practice. Cox's regression models compared attendance rates and time until first attendance between those families who received support from the DHSW and those who did not. RESULTS: The cohort consisted of 35236 children. Thirty-three percent of the cohort (n = 11495) were considered to require additional support from a DHSW. Of these, 44% (5087) received that support. These families were more likely to attend a dental practice (Hazard Ratio [95% Confidence Interval] =1.87 [1.8 to 1.9]) and, on average, did so 9 months earlier (median time until first attendance: 8.8 months versus 17.8 months), compared to families not receiving additional support. CONCLUSIONS: Link workers (DHSW) within the Childsmile programme are effective at linking targeted children to primary care dental services and, most notably, at a younger age for prevention. This is the first study of its kind to evaluate the effectiveness of link-worker programmes using a robust quasi-experimental design on three, population-wide, linked datasets. These results will inform future health programmes which aim to improve health and reduce inequalities by reaching and supporting families from more disadvantaged backgrounds.

The effect of introducing a financial incentive to promote application of fluoride varnish in dental practice in Scotland: a natural experiment.

BACKGROUND: Financial incentives are often used to influence professional practice, yet the factors which influence their effectiveness and their behavioural mechanisms are not fully understood. In keeping with clinical guidelines, Childsmile (Scotland's oral health improvement programme) advocates twice yearly fluoride varnish application (FVA) for children in dental practice. To support implementation Childsmile offered dental practitioners a fee-per-item payment for varnishing 2-5-year-olds' teeth through a pilot. In October 2011 payment was extended to all dental practitioners. This paper compares FVA pre- and post-roll-out and explores the financial incentive's behavioural mechanisms. METHODS: A natural experimental approach using a longitudinal cohort of dental practitioners (n = 1090) compared FVA pre- (time 1) and post- (time 2) financial incentive. Responses from practitioners who did not work in a Childsmile pilot practice when considering their 2-5-year-old patients (novel incentive group) were compared with all other responses (continuous incentive group). The Theoretical Domains Framework (TDF) was used to measure change in behavioural mechanisms associated with the incentive. Analysis of covariance was used to investigate FVA rates and associated behavioural mechanisms in the two groups. RESULTS: At time 2, 709 74%, of eligible responders, were followed up. In general, FVA rates increased over time for both groups; however, the novel incentive group experienced a greater increase (ß [95% CI] = 0.82 [0.72 to 0.92]) than the continuous incentive group. Despite this, only 33% of practitioners reported 'always' varnishing increased risk 2-5-year-olds' teeth following introduction of the financial incentive, 19% for standard risk children. Domain scores at time 2 (adjusting for time 1) increased more for the novel incentive group (compared to the continuous incentive group) for five domains: knowledge, social/professional role and identity, beliefs about consequences, social influences and emotion. CONCLUSIONS: In this large, prospective, population-wide study, a financial incentive moderately increased FVA in dental practice. Novel longitudinal use of a validated theoretical framework to understand behavioural mechanisms suggested that financial incentives operate through complex inter-linked belief systems. While financial incentives are useful in narrowing the gap between clinical guidelines and FVA, multiple intervention approaches are required.

A systems approach using the functional resonance analysis method to support fluoride varnish application for children attending general dental practice.

BACKGROUND: All children attending General Dental Practice in Scotland are recommended to receive twice-yearly applications of sodium fluoride varnish to prevent childhood caries, yet application is variable. Development of complex interventions requires theorizing and modelling to understand context. This study applies the Functional Resonance Analysis Method (FRAM) to produce a sociotechnical systems model and identify opportunities for intervention to support application. METHODS: The FRAM was used to synthesise data which were: routine monitoring of fluoride varnish application in 2015/16; a longitudinal survey with practitioners (n = 1090); in-depth practitioner and key informant interviews (n = 43); and a 'world café' workshop (n = 56). RESULTS: We describe a detailed model of functions linked to application, and use this to make recommendations for system-wide intervention. CONCLUSIONS: Rigorous research is required to produce accessible models of complex systems in healthcare. This novel paper shows how careful articulation of the functions associated with fluoride varnish application can support future improvement efforts.

Linking families with pre-school children from healthcare services to community resources: a systematic review protocol.

BACKGROUND: Poor health and health inequalities persist despite increasing investment in health improvement programmes across high-income countries. Evidence suggests that to reduce health inequalities, a range of activities targeted at different levels within society and throughout the life course should be employed. There is a particular focus on addressing inequalities in early years as this may influence the experience of health in adulthood. To address the wider determinants of health at a community level, a key intervention which can be considered is supporting patients to access wider community resources. This can include processes such as signposting, referral and facilitation. There is a lack of evidence synthesis in relation to the most effective methods for linking individuals from health services to other services within communities, especially when considering interventions aimed at families with young children. METHOD/DESIGN: The aim of this study is to understand the way health services can best help parents, carers and families with pre-school children to engage with local services, groups and agencies to address their wider health and social needs. The review may inform future guidance to support families to address wider determinants of health. The study is a systematic review, and papers will be identified from the following electronic databases: Web of Science, Embase, MEDLINE and CINAHL. A grey literature search will be conducted using an internet search engine and specific grey literature databases (TRiP, EThOS and Open Grey). Reference lists/bibliographies of selected papers will be searched. Quality will be assessed using the Effective Public Health Practice Project Quality Assessment Tool for quantitative studies and the CASP tool for qualitative studies. Data will be synthesised in a narrative form and weighted by study quality. DISCUSSION: It is important to understand how health services can facilitate access to wider services for their patients to address the wider determinants of health. This may impact on the experience of health inequalities. This review focuses on how this can be achieved for families with pre-school children, and the evidence obtained will be useful for informing future guidance on this topic. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016034066.

How lay health workers tailor in effective health behaviour change interventions: a protocol for a systematic review.

BACKGROUND: Lay health workers (LHWs) are utilised as a channel of delivery in many health interventions. While they have no formal professional training related to their role, they utilise their connections with the target group or community in order to reach individuals who would not normally readily engage with health services. Lay health worker programmes are often based on psychological theories of behaviour change that point to 'tailoring to individuals' needs or characteristics' as key to success. Although lay health workers have been shown to be effective in many contexts, there is, as yet, little clarity when it comes to how LHWs assess individuals' needs in order to tailor their interventions. This study aims to develop a better understanding of the effective implementation of tailoring in lay health worker interventions by appraising evidence and synthesising studies that report evaluations of tailored interventions. METHOD: Health and psychology electronic databases (EMBASE, CINAHL, MEDLINE and PsycINFO) will be searched. Reference lists of included studies will also be searched. For articles that are deemed to be potentially relevant, we will employ a 'cluster searching' technique in order to identify all published papers related to a relevant intervention. Cluster searching will be undertaken in an effort to maximise the breadth and depth of description of the intervention. Quantitative studies will be assessed using the Quality Assessment Tool for Quantitative Studies, developed by the Effective Public Health Practice Project, ON, Canada. Qualitative studies will be assessed using the Critical Appraisal Skills Programme (CASP) checklist for qualitative research. Sythesising the data will enable the development of a taxonomy of strategies for the criteria used for individual assessment of recipients' needs and the ways in which messages or actions are tailored to these individual criteria by LHWs. DISCUSSION: This systematic review focuses specifically on how health promotion and support is individually tailored in effective programmes by LHWs. This study will be of value to those involved in the design and implementation of interventions that utilise a LHW. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015030071.

Patient-, organization-, and system-level barriers and facilitators to preventive oral health care: a convergent mixed-methods study in primary dental care.

BACKGROUND: Dental caries is the most common chronic disease of adult and childhood, a largely preventable yet widespread, costly public health problem. This study identified patient-, organization-, and system-level factors influencing routine delivery of recommended care for prevention and management of caries in primary dental care. METHODS: A convergent mixed-methods design assessed six guidance-recommended behaviours to prevent and manage caries (recording risk, risk-based recall intervals, applying fluoride varnish, placing preventive fissure sealants, demonstrating oral health maintenance, taking dental x-rays). A diagnostic questionnaire assessing current practice, beliefs, and practice characteristics was sent to a random sample of 651 dentists in National Health Service (NHS) Scotland. Eight in-depth case studies comprising observation of routine dental visits and dental team member interviews were conducted. Patient feedback was collected from adult patients with recent checkups at case study practices. Key informant interviews were conducted with decision makers in policy, funding, education, and regulation. The Theoretical Domains Framework within the Behaviour Change Wheel was used to identify and describe patient-, organization-, and system-level barriers and facilitators to care. Findings were merged into a matrix describing theoretical domains salient to each behaviour. The matrix and Behaviour Change Wheel were used to prioritize behaviours for change and plan relevant intervention strategies. RESULTS: Theoretical domains associated with best practice were identified from the questionnaire (N-196), case studies (N = 8 practices, 29 interviews), and patient feedback (N = 19). Using the study matrix, key stakeholders identified priority behaviours (use of preventive fissure sealants among 6-12-year-olds) and strategies (audit and feedback, patient informational campaign) to improve guidance implementation. Proposed strategies were assessed as appropriate for immediate implementation and suitable for development with remaining behaviours. CONCLUSIONS: Specific, theoretically based, testable interventions to improve caries prevention and management were coproduced by patient-, practice-, and policy-level stakeholders. Findings emphasize duality of behavioural determinants as barriers and facilitators, patient influence on preventive care delivery, and benefits of integrating multi-level interests when planning interventions in a dynamic, resource-constrained environment. Interventions identified in this study are actively being used to support ongoing implementation initiatives including guidance, professional development, and oral health promotion.

Elimination of 'the Glasgow effect' in levels of dental caries in Scotland's five-year-old children: 10 cross-sectional surveys (1994-2012).

BACKGROUND: Socioeconomic inequalities in health within Glasgow, Scotland, are among the widest in the world. This is largely attributed to socio-economic conditions. The 'Glasgow Effect' labels the finding that the high prevalence of some diseases cannot be fully explained by a conventional area-based socio-economic metric. This study aimed to investigate whether differences in dental caries between Glasgow's resident children and those in the Rest of Scotland could be explained by this metric and whether differences were of fixed magnitude, over time. METHODS: Scotland's National Dental Inspection Programme (NDIP) cross-sectional data for five-year-old children in years: 1994, 1996, 1998, 2000, 2003, 2004, 2006, 2008, 2010, and 2012 (n = 92,564) were utilised. Endpoints were calculated from the mean decayed, missing and filled teeth score (d3mft) and percentage with obvious decay experience. Socioeconomic status was measured by DepCat, a Scottish area-based index. The Glasgow Effect was estimated by the odds-ratio (OR) of decay for Glasgow versus the Rest of Scotland adjusted by age, gender and DepCat. Inequalities were also assessed by the Significant Caries Index (SIC), SIC 10, and Scottish Caries Inequality Metric (SCIM 10). RESULTS: Decay levels for deprived Glasgow children have reduced to be similar to those in the Rest of Scotland. In 1993, OR for d3mft > 0 for those living in the Glasgow area was 1.34(1.10, 1.64), p = 0.005. This reduced below unity in 2012, OR = 0.85(0.77, 0.93), p < 0.001. There were downward trends (p < 0.001) in absolute inequality measured by SIC and SIC 10 in each of the geographic areas. The SCIM 10 demonstrated further reductions in inequality across the population. The downward trends for all the inequality measures were larger for Glasgow than the Rest of Scotland. CONCLUSIONS: Over the interval, Glasgow has eliminated the earlier extra health inequalities. When comparing 'like for like' by socioeconomic status there is now no higher level of dental caries in the Greater Glasgow area.

Use of the theoretical domains framework to further understanding of what influences application of fluoride varnish to children's teeth: a national survey of general dental practitioners in Scotland.

OBJECTIVES: Despite recent improvements in the oral health of Scotland's population, the persistence of childhood dental caries underscores a need to reduce the disease burden experienced by children living in Scotland. Application of fluoride varnish (FV) to children's teeth provides an evidence-based approach to achieving this goal. Despite policy, health service targets and professional recommendations supporting application, not all children receive FV in line with guidance. The objective of this study was to use the theoretical domains framework (TDF) to further an understanding of what may influence fluoride varnish application (FVA) in General Dental Practice in Scotland. METHODS: A postal questionnaire assessing current behaviour (frequency of FVA) and theoretical domains (TDs) was sent to all General Dental Practitioners (GDPs) in Scotland. Correlations and linear regression models were used to examine the association between FVA and the TDs. RESULTS: One thousand and ninety (53.6%) eligible GDPs responded. Respondents reported applying FV more frequently to increased risk and younger children (aged 2-5 years). Higher scores in eight TDs (Knowledge, Social/professional role and identity, Beliefs about consequences, Motivation and goals, Environmental context and resources, Social influences, Emotion and Behavioural regulation) were associated with greater frequency of FVA. Four beliefs in particular appear to be driving GDPs' decision to apply FV (recognizing that FVA is a guideline recommended behaviour (Knowledge), that FVA is perceived as an important part of the GDPs' professional role (Professional role/identity), that FV is something parents want for their children (Social influences) and that FV is something GDPs really wanted to do (Emotion). CONCLUSIONS: The findings of this study support the use of the TDF as a tool to understand GDPs application of FV and suggest that a multifaceted intervention, targeting dental professionals and families, and more specifically those domains and items associated with FVA may have the greatest likelihood of influencing the evidence-based behaviour.

Extending dental nurses' duties: a national survey investigating skill-mix in Scotland's child oral health improvement programme (Childsmile).

BACKGROUND: Childsmile is Scotland's national child oral health improvement programme. To support the delivery of prevention in general dental practice in keeping with clinical guidelines, Childsmile sought accreditation for extended duty training for dental nurses to deliver clinical preventive care. This approach has allowed extended duty dental nurses (EDDNs) to take on roles traditionally undertaken by general dental practitioners (GDPs). While skill-mix approaches have been found to work well in general medicine, they have not been formally evaluated in dentistry. Understanding the factors which influence nurses' ability to fully deliver their extended roles is necessary to ensure nurses' potential is reached and that children receive preventive care in line with clinical guidance in a cost-effective way. This paper investigates the supplementation of GDPs' roles by EDDNs, in general dental practice across Scotland. METHODS: A cross-sectional postal survey aiming to reach all EDDNs practising in general dental practice in Scotland was undertaken. The survey measured nurses': role satisfaction, perceived utility of training, frequency, and potential behavioural mediators of, preventive delivery. Frequencies, correlations and multi-variable linear regression were used to analyse the data. RESULTS: Seventy-three percent of practices responded with 174 eligible nurses returning questionnaires. Respondents reported a very high level of role satisfaction and the majority found their training helpful in preparing them for their extended role. While a high level of preventive delivery was reported, fluoride vanish (FV) was delivered less frequently than dietary advice (DA), or oral hygiene advice (OHA). Delivering FV more frequently was associated with higher role satisfaction (p < 0.001). Those nurses who had been practising longer reported delivering FV less frequently than those more recently qualified (p < 0.001). Perceived difficulty of delivering preventive care (skills) and motivation to do so were most strongly associated with frequency of delivery (p < 0.001 for delivery of FV, DA and OHA). CONCLUSIONS: This study has provided insight into EDDNs' experiences and demonstrates that with appropriate training and support, EDDNs can supplement GDPs' roles in general dental practice in Scotland. However, some barriers to delivery were identified with delivery of FV showing scope for improvement.

Can programme theory be used as a 'translational tool' to optimise health service delivery in a national early years' initiative in Scotland: a case study.

BACKGROUND: Theory-based evaluation (TBE) approaches are heralded as supporting formative evaluation by facilitating increased use of evaluative findings to guide programme improvement. It is essential that learning from programme implementation is better used to improve delivery and to inform other initiatives, if interventions are to be as effective as they have the potential to be. Nonetheless, few studies describe formative feedback methods, or report direct instrumental use of findings resulting from TBE. This paper uses the case of Scotland's, National Health Service, early years', oral health improvement initiative (Childsmile) to describe the use of TBE as a framework for providing feedback on delivery to programme staff and to assess its impact on programmatic action. METHODS: In-depth, semi-structured interviews and focus groups with key stakeholders explored perceived deviations between the Childsmile programme 'as delivered' and its Programme Theory (PT). The data was thematically analysed using constant comparative methods. Findings were shared with key programme stakeholders and discussions around likely impact and necessary actions were facilitated by the authors. Documentary review and ongoing observations of programme meetings were undertaken to assess the extent to which learning was acted upon. RESULTS: On the whole, the activities documented in Childsmile's PT were implemented as intended. This paper purposefully focuses on those activities where variation in delivery was evident. Differences resulted from the stage of roll-out reached and the flexibility given to individual NHS boards to tailor local implementation. Some adaptations were thought to have diverged from the central features of Childsmile's PT, to the extent that there was a risk to achieving outcomes. The methods employed prompted national service improvement action, and proposals for local action by individual NHS boards to address this. CONCLUSIONS: The TBE approach provided a platform, to direct attention to areas of risk within a national health initiative, and to agree which intervention components were 'core' to its hypothesised success. The study demonstrates that PT can be used as a 'translational tool' to facilitate instrumental use of evaluative findings to optimise implementation within a complex health improvement programme.

CATCH: development of a home-based midwifery intervention to support young pregnant smokers to quit.

OBJECTIVE: to develop, implement and evaluate a supportive midwifery intervention, Community Action on Tobacco for Children's Health (CATCH), to help young pregnant smokers to quit. DESIGN: action research project funded from April 2002 to June 2005. SETTING AND PARTICIPANTS: CATCH was based in a single hospital maternity unit in the West of Scotland and targeted a deprived population of pregnant smokers aged 25 years and under. Outreach work was undertaken in the local community and cessation support was provided in women's own homes. INTERVENTION: CATCH aimed to meet the particular needs of young pregnant women through a tailored, non-judgmental approach. The service was distinctive as it employed a holistic approach to smoking cessation which focused not only on individual choices and motivations, but on the wider life circumstances that may preclude behaviour change. MEASURES: internal and external teams collaborated to ensure a comprehensive evaluation, gathering of both process and outcome data. Outcomes (including self-reported and carbon monoxide validated quit status) were assessed by quantitative surveys undertaken at enrolment to the service and at 3- and 12-month follow-up. All those lost to follow-up were assumed to still be smoking. Participants' views of the service were gathered independently by an external evaluation team, and a detailed qualitative case study, capturing ongoing learning, was undertaken. Data were collected from participants who joined the project over a 16-month period (November 2002-February 2004). FINDINGS: the study demonstrated a feasible approach to engaging young pregnant smokers to help them quit. Obstetricians and midwives were willing to refer to a service based in their maternity unit run by a specially trained midwife, and users reported a positive experience of the service. Of 152 eligible clients referred within the 16-month period, 79 (52%) joined CATCH. Of those who joined, 18 (22.8%) were self-reported non-smokers at 3 months, of whom 16 (20.3%) were validated as non-smokers using carbon monoxide monitoring. Thirteen (16.5%) clients reported being smoke free at 12 months, of whom 10 (12.7%) were validated as non-smokers at 12 months. IMPLICATIONS FOR PRACTICE: CATCH suggests that close partnership with the multi-disciplinary maternity team and integration into the maternity system is invaluable for smoking cessation services targeting pregnant women. It points to the benefits of the service being delivered by a trained midwife in clients' own homes. Flexibility and a non-judgmental approach are essential to engagement. Attention to the context and wider circumstances of clients' lives and involving friends and family enables clients to focus on their own smoking.

A Scotland-wide pilot programme of smoking cessation services for young people: process and outcome evaluation.

AIM: To conduct an independent, external evaluation of a Scotland-wide youth cessation pilot programme, focusing upon service uptake and effectiveness. INTERVENTION: National Health Service (NHS) Health Scotland and Action on Smoking and Health (ASH) Scotland funded a 3-year (2002-2005) national pilot programme comprising eight projects which aimed to engage with and support young smokers (aged 12-25 years) to quit. DESIGN, PARTICIPANTS AND MEASUREMENTS: Process evaluation was undertaken via detailed case studies comprising qualitative interviews, observation and documentary analysis. Outcomes were assessed by following project participants (n=470 at baseline) at 3 and 12 months and measuring changes in smoking behaviour, including carbon monoxide (CO)-validated quit status. FINDINGS: Recruitment proved difficult. Considerable time and effort were needed to attract young smokers. Advertising and recruitment had to be tailored to project settings and educational activities proved essential to raise the profile of smoking as an issue. Thirty-nine participants [8.6%, 95% confidence interval (CI) 5.0-11.2%] were CO-validated quitters at 3 months and 11 of these (2.4%, 95% CI 1.90-3.8%) were also validated quitters at 12 months. Older participants were more likely to be abstinent at 3 months. CONCLUSIONS: The overall quit rate was disappointing. As a result of low participant numbers, it was impossible to draw conclusions about the relative effectiveness of different project approaches. These findings give little support to the case for developing dedicated youth cessation services in Scotland. They also highlight the difficulties of undertaking 'real-world' evaluations of pilot youth cessation projects. More action is needed to develop environments which enhance young smokers' motivation to quit and their ability to sustain quit attempts.

'People pull the rug from under your feet': barriers to successful public health programmes.

BACKGROUND: A community public health programme, 'Breathing Space', aimed to tackle smoking in a low income area in Scotland. This paper draws on the qualitative process evaluation of a community-based initiative 'Breathing Space', which set out to tackle smoking in a low income area of Scotland, in order to explore user perceptions of key factors affecting implementation, and in particular to explore the implications of participant knowledge and expertise for programme stability and continuity. METHODS: The overall evaluation of Breathing Space used a quasi-experimental design and incorporated a detailed process evaluation. The process evaluation aimed to document development and implementation of the programme using a range of qualitative methods, including observation, in-depth interviews, focus groups and documentary analysis. The paper draws upon 59 semi-structured in-depth interviews which were carried out as part of the process evaluation. FINDINGS: Staff numbers from the multi-agency partnership dwindled across the lifecouof the programme and respondents identified lack of continuity as a key issue. While staff changes are an anticipated problem in programme implementation, here we draw on concepts of technicality and indeterminacy to explore the different aspects of public health programmes which are forfeited when individuals leave. The paper argues that, while technical components of public health programmes (such as the importance of staff complement and continuity) are widely recognised, it is the more indeterminate aspects, including the loss of key theoretical understanding underpinning the programme, which most affect programme delivery. Indeed, the paper suggests that, where inadequate planning and resources threaten the continuity of indeterminate knowledge, the success of public health programmes may be especially jeopardised. CONCLUSION: Community-based programmes which rely strongly on partnership processes would benefit from early consideration of the potential risks associated with both expected and unexpected stakeholder change. Building in appropriate contingency plans is necessary for sustaining the theory and culture of the programme. Evaluations of innovative community development initiatives may benefit from a formative approach.

Issues of participation, ownership and empowerment in a community development programme: tackling smoking in a low-income area in Scotland.

Founded on community development principles and practice, the 'Breathing Space' initiative aimed to produce a significant shift in community norms towards non-toleration and non-practice of smoking in a low-income area in Edinburgh, Scotland. The effectiveness of Breathing Space was evaluated using a quasi-experimental design, which incorporated a process evaluation in order to provide a description of the development and implementation of the intervention. Drawing on qualitative data from the process evaluation, this paper explores the varied and sometimes competing understandings of the endeavour held by those implementing the intervention. The paper examines the principles that underpin health promotion in the community setting, particularly the concepts of ownership, empowerment and participation, and their differential interpretation and employment by participants. The data illustrate how these varied understandings had implications for the joint planning and implementation of Breathing Space objectives. In addition, the different understandings raise questions about the appropriateness and viability of utilizing community development approaches in this context.