No date for the PROM: the association between patient-reported health events and clinical coding in primary care.

OBJECTIVE: It is unclear whether data from patient-reported outcome measures (PROMs) are captured and used by clinicians despite policy initiatives. We examined the extent to which fall risk and urinary incontinence (UI) reported on PROMS and provided to clinicians prior to a patient visit are subsequently captured in the electronic medical record (EMR). Additionally, we aimed to determine whether the use of PROMs and EMR documentation is higher for visits where PROM data was provided to clinicians. DESIGN: We conducted a cross-sectional patient-reported risk assessment survey and semi-structured interviews with clinicians to identify themes related to the use of PROMs. SETTING: Fourteen primary care clinics in the US (eight intervention and six control clinics), between October 2013 and May 2015. PARTICIPANTS: Primary care clinicians and older adult (≥66 years) patients completing a 46-item health risk assessment, including PROMs for fall risk and UI. INTERVENTION: Risk assessment results provided to the clinician or nurse practitioners prior to the clinic visit in intervention clinics; data was not provided in control clinics. MAIN OUTCOME: 1) Agreement between ICD-9 codes of fall risk or UI in the EMR and patient-reports, and 2) clinician experience of PROMs use and impact on coding. RESULTS: A total of 505 older adult patients were included in the study, 176 at control clinics and 329 at intervention clinics. While patient reports of fall risk and UI were readily captured by PROMs, this information was only coded in the EMR between 3% - 14% of the time (poor Kappa agreement). Intervention clinics performed slightly better than control clinics. Clinician interviews (n = 16) revealed low use of PROMs data with multiple barriers cited including poor access to data, high quantity of data, interruption to workflow, and a lack of training on PROMs. CONCLUSIONS: Current strategies of providing PROMs data prior to clinic visits may not be an effective way of communicating important health information to busy clinicians; ultimately resulting in underuse. Better systems of presenting PROMs data, and clinician training on the importance of PROMs and their use, is needed.

Stigma among California's Medical Marijuana Patients.

The enactment of California's Proposition 215 stipulates that patients may use marijuana for medical reasons, provided that it is recommended by a physician. Yet, medical marijuana patients risk being stigmatized for this practice. This article examines the way in which medical marijuana patients perceive and process stigma, and how it affects their interactions and experiences with others. Eighteen semi-structured interviews of medical marijuana patients were carried out using a semi-structured interview guide. Most patients circumvented their own physicians in obtaining a recommendation to use medicinal marijuana, and also used a host of strategies in order to justify their medical marijuana use to family, friends, and colleagues in order to stave off potential stigma. The stigmatization of medical marijuana thus has a profound effect on how patients seek treatment, and whether they seek medical marijuana treatment at all.

Evaluating local policy adoption campaigns in California: Tobacco Retail License (TRL) adoption.

As part of its state-wide "denormalization" campaign, the California Tobacco Control Program has funded local tobacco control projects to secure tobacco retail licenses (TRLs) in their communities. TRL policies generate funding by requiring tobacco retailers within a jurisdiction to obtain a license, which is in addition to the state license that tobacco retailers are legally required to purchase to sell tobacco products. The funding provided by TRLs enables local law enforcement to carry out inspection and enforcement operations. This paper examines the unique processes by which local project campaigns attempt to get TRL policies adopted in communities across the State of California. Twenty-two local projects submitted final evaluation reports pertaining to the adoption of TRLs, and the reports from these projects form the basis of the analysis. Successful campaigns tended to include the following strategies: (1) determining policy readiness; (2) gathering local data; (3) identifying and working with a "champion"; (4) building relationships with local law enforcement agencies and decision makers; and (5) educating community and decision makers. The major challenges faced by local projects included budget cuts and staffing issues, concern about creating an unfavorable environment for business by imposing more regulations and fees, and complaints about using law enforcement resources for tobacco control in light of more "pressing" public safety issues. These challenges proved difficult for local projects to overcome, and also highlight the need for projects to create and carry out strong but flexible tactical plans that incorporate the aforementioned strategies.

A qualitative evaluation of 40 voluntary, smoke-free, multiunit, housing policy campaigns in California.

BACKGROUND: Although it is legal for multiunit housing (MUH) property owners in all 50 states to prohibit smoking on their premises, including in individual units, MUH constitutes a relatively new setting to reduce exposure to secondhand smoke via voluntary smoke-free policy. This paper examines California state-funded smoke-free MUH policy campaigns between 2004 and 2010. METHODS: A cross-case analysis of 40 state-funded smoke-free MUH policy campaigns was conducted via an examination of final evaluation reports submitted to the California Tobacco Control Program. RESULTS: The most effective voluntary smoke-free MUH policy campaigns typically included: (1) learning the local [MUH] context, (2) finding and using a champion, (3) partnering with like-minded organisations, (4) building relationships with stakeholders, (5) collecting and using local data and (6) making a compelling case to decision makers. DISCUSSIONS: The aforementioned steps tended to be intertwined, and successfully securing voluntary smoke-free MUH policy required a strategic but flexible plan of implementation prior to entrance into the field. Campaigns designed to enhance voluntary smoke-free MUH policy adoption should underscore the economic viability of such policies during each strategic step.

Accommodating diverse clients' needs in evaluation capacity building: a case study of the Tobacco Control Evaluation Center.

In this case study, we detail and analyze how the Tobacco Control Evaluation Center (TCEC), an evaluation technical assistance center that serves approximately 100 local tobacco control organizations in California, endeavors to build capacity among the state-funded local providers it serves by using evaluation capacity building activities with an utilization-focused evaluation framework. We call this a "blended approach" and describe these methods. Satisfaction and demand for TCEC services are documented to provide measurements for evaluation capacity building. Final evaluation report scores from two intervention cycles (2004-2007 and 2007-2010) submitted to the California Health Department, Tobacco Control Division are also assessed and compared. These measures demonstrate an increase in evaluation capacity by local projects under TCEC's purview.

Navigating local smoke-free multi-unit housing policy adoption.

California state-funded local tobacco control projects have instituted smoke-free multi-unit housing (MUH) policy adoption campaigns in order to secure voluntary policy throughout the state. While landlords can legally prohibit smoking at MUH complexes in California, they often oppose such measures. The objective of this study was to analyze voluntary smoke-free policy campaigns of state-funded local projects by focusing on the challenges they faced. Specifically, we examined 40 local campaigns in California led by county health departments and community based organizations, focusing on the barriers the local projects often had to overcome to enact policy. Our results identify arguments and issues typically raised by MUH property landlords, including the notion of tenant smoker and privacy rights, potential negative effects of smoke-free policy, and issues concerning the enforcement of policy. Moreover, relationships between local project personnel and MUH management often soured, which sometimes derailed smoke-free policy campaigns altogether. Our findings provide agencies with insights from the MUH property landlord perspective that will serve to inform future campaign strategy.

Achieving smoke-free apartment outdoor area policies in Asian/Pacific islander neighborhoods of central Los Angeles.

Attempting to achieve non-smoking outdoor area policies in apartment complexes of Central Los Angeles Asian/Pacific Islander neighborhoods, People's CORE, a community based organization, partnered with a professional evaluator for a three year campaign. Focus group discussion results with residents showed readiness as well as hesitation towards non-smoking policies. Through community organizing, focus group discussions with tenants and one-on-one education outreach activities to apartment managers, the organization managed to have 20 apartment complexes adopt and implement policies for smoking restrictions in their common outdoor areas. Pre- and post observations at 52 apartment complexes showed statistically significant reduction of tobacco litter in parking areas/garages, entrance ways, courtyards, and balcony/walkway/community rooms. The authors attribute the success of the project in part to the long-standing good reputation of People's CORE as a community mobilizer and organizer.

Changes in smoking-related norms in bars resulting from California's Smoke-Free Workplace Act.

California's Smoke-Free Workplace Act--CA Labor Code Sec. 6404.5(a)--was extended to bars in 1998. This article analyzes changes in normative beliefs and behaviors related to bar smoking in the decade following the adoption of the Act. In a series of studies evaluating the smoke-free workplace law in bars, researchers conducted extensive observations and interviews with bar staff and patrons, health officials, and law enforcement personnel in three California counties. Smoking outside became a normal pause in the social environment and created a new type of bar socializing for outside smokers. Although some bar owners and staff reported initially resenting the responsibility to uphold the law, once norms regarding cigarettes and smoking began changing, bar workers experienced less conflict in upholding the law. Non-smoking behavior within bars also became the normative behavior for bar patrons. California's Smoke-Free Workplace Act has both reflected and encouraged normative beliefs and behaviors related to smoking in bars. The findings indicate that such shifts are possible even in contexts where smoking behaviors and attitudes supporting smoking were deeply entrenched. Recommendations include attending to the synergistic effect of education and policy in effective tobacco control programs.

Building the evaluation capacity of California's local tobacco control programs.

Successful evaluation capacity building requires a dynamic balance between responding to local agency needs and ensuring that local staff have appropriate skills to conduct rigorous evaluations. In 2004, the California Tobacco Control Program established the Tobacco Control Evaluation Center (TCEC), based at a public research university, to provide evaluation technical assistance to approximately 100 local agencies implementing tobacco control programs. TCEC has been responsive to local needs, for instance, by answering 512 technical assistance requests in the first 5 years of operation and by tailoring training according to needs assessment results. About 50% of the technical assistance requests were for new data collection instruments (n = 255). TCEC has sought proactively to improve local evaluation skills, most recently in a data analysis and report writing skill building campaign that included a webinar, newsletter, and seven regional training meetings. Preliminary analysis suggests a 20% improvement in scores for the local final evaluation reports as a result of this campaign. It is concluded that evaluation technical assistance can be provided effectively by a university as long as the local context is kept in mind, and a balance of responsive and proactive technical assistance is provided.

Strategies implemented by 20 local tobacco control agencies to promote smoke-free recreation areas, California, 2004-2007.

INTRODUCTION: Since 2000, local jurisdictions in California have enacted hundreds of policies and ordinances in an effort to protect their citizens from the harmful effects of secondhand smoke. We evaluated strategies used by state-funded local tobacco control programs to enact local smoke-free policies involving outdoor recreational spaces. METHODS: The Tobacco Control Evaluation Center analyzed 23 final evaluation reports that discussed adopting local smoke-free policies in outdoor recreational facilities in California. These reports were submitted for the 2004 through 2007 funding period by local tobacco control organizations to the California Department of Public Health, Tobacco Control Program. We used a comparative technique whereby we coded passages and compared them by locale and case, focusing on strategies that led to the enactment of smoke-free policies. RESULTS: Our analysis found the following 6 strategies to be the most effective: 1) having a "champion" who helps to carry an objective forward, 2) tapping into a pool of potential youth volunteers, 3) collecting and using local data as a persuasive tool, 4) educating the community in smoke-free policy efforts, 5) working strategically in the local political climate, and 6) framing the policy appropriately. CONCLUSION: These strategies proved effective regardless of whether policies were voluntary, administrative, or legislative. Successful policy enactment required a strong foundation of agency funding and an experienced and committed staff. These results should be relevant to other tobacco control organizations that are attempting to secure local smoke-free policy.

Barriers to adopting and implementing local-level tobacco control policies.

Although California communities have been relatively successful in adopting and implementing a wide range of local tobacco control policies, the process has not been without its setbacks and barriers. Little is known about local policy adoption, and this paper examines these processes related to adopting and implementing outdoor smoke-free policies, focusing on the major barriers faced by local-level tobacco control organizations in this process. Ninety-six projects funded by the California Tobacco Control Program submitted final evaluation reports pertaining to an outdoor smoking objective, and the reports from these projects were analyzed. The barriers were grouped in three primary areas: politically polarizing barriers, organizational barriers, and local political orientation. The barriers identified in this study underscore the need for an organized action plan in adopting local tobacco policy. The authors also suggest potential strategies to offset the barriers, including: (1) having a "champion" who helps to carry an objective forward; (2) tapping into a pool of youth volunteers; (3) collecting and using local data as a persuasive tool; (4) educating the community in smoke-free policy efforts; (5) working strategically within the local political climate; and (6) demonstrating to policymakers the constituent support for proposed policy.

Law in practice: obstacles to a smokefree workplace policy in bars serving Asian patrons.

The California smokefree workplace ordinance (AB13) has been well-received, even in bars where deeply established traditions of smoking may exist. However, a closer investigation of bars where indoor smoking persists revealed that bar workers in some ethnic minority communities continue to be exposed to secondhand smoke in their workplaces. To identify sociocultural factors that may impede the adoption of AB13, the researchers conducted 150 observations and 29 patron and staff interviews in 50 California bars serving Asian patrons in Los Angeles and San Francisco counties. Observers witnessed indoor smoking in 82% of the bars. Interviews revealed that social relationships, social interactions, and a tendency to avoid confrontation complicated the positive reception of AB13 within these bars. Accounting for sociocultural factors provides a nuanced understanding of the challenges involved in implementing tobacco control policy in such diverse settings and may allow for culturally appropriate tobacco policy development and implementation in other jurisdictions.

Cultural factors related to smoking in San Francisco's Irish bars.

California's Smoke-Free Workplace Act was extended to include bars in 1998. While the majority of bars in the state have become smoke free, in many bars patrons and staff continue to smoke despite the law. The authors present findings from a study which assessed cultural factors related to continued smoking in bars in the city of San Francisco. In bars serving primarily Irish migrants, tight-knit relations within the local Irish bar community together with a reluctance to be the first Irish bar to ban smoking were found to contribute to continued indoor smoking. The findings illustrate challenges to implementing tobacco control policies within ethnic subpopulations and particularly highlight the importance of considering how cultural dynamics within subpopulations may help or hinder such policies.

CHALLENGES TO IMPLEMENTING AND ENFORCING CALIFORNIA'S SMOKE-FREE WORKPLACE ACT IN BARS.

California's 1995 Smoke-Free Workplace Act-Assembly Bill 13 (AB 13)-was extended to bars in 1998. This paper examines the challenges faced by officials responsible for implementing and enforcing the law. As part of a series of studies evaluating AB 13 in bars, researchers conducted confidential in-depth interviews with 35 state, county and municipal authorities and representatives of non-governmental agencies. The interviews were recorded, transcribed, coded and analyzed by themes and respondent categories. Data from structured observations in sampled bars and interviews with bar staff and patrons offer contextual information. Analyses indicated the following challenges: 1) an ineffective administrative structure, 2) problems associated with the complaint-driven system used to enforce the law, 3) lack of funding for enforcement, 4) low prioritization of enforcement, and 5) the minimal deterrence effect of the sanctioning penalties. The findings indicate why indoor smoking may continue in some bars despite the state law prohibiting smoking in workplaces. Many municipalities, states and countries may be considering restricting smoking in workplaces including bars, and our findings show that clear delineation of procedures and enforcement criteria, as well as funding and substantive penalties, should be considered in drafting these laws.