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CHAPTER 7: SUPPORTED PROJECTS

Summary

Achievements

Achievements of the PATH-funded projects

7.1 The strategic objectives of the PATH Supported Fund are to:

• Allocate and evaluate a fund of almost £1m to enable the delivery of innovative tobacco and health initiatives aimed particularly at low-income groups and pregnant women;
• Identify and disseminate evidence of good practice and of barriers to effective interventions in specific settings or with specific target groups.

7.2 PATH allocated about £900,000 from its Support Fund to 11 ⁴⁴ creative local pilot initiatives around Scotland exploring different approaches to tobacco work amongst identified priority groups. These priority groups were pregnant women and people faced with inequalities (specifically, older adults; ethnic minority groups; people on low incomes; and people with mental health needs and disability). All of the projects had start/end dates during the period 2003 to 2007, which means that much of the initial work was undertaken during the period of PATH's first tranche of funding. Each project submitted regular progress reports to PATH on the achievement of milestones, general progress, and issues arising from their work. Much of this information can be downloaded via the PATH section of the ASH Scotland website. ⁴⁵

7.3 The projects fell into two broad categories:

• Intervention-based (mostly hosted within service delivery settings);
• Research-based (mostly hosted within a University).

7.4 The following intervention-based projects were supported. The original levels of PATH funding (which total almost £654,000 for the intervention-based projects and about £186,000 for the research-based projects) are shown in brackets, although supplementary amounts were subsequently awarded to some projects (and some projects returned unspent funds to PATH).

• Stop for Life (£117,654) - West Lothian NHS Healthcare Division: individual smoking cessation counselling for pregnant women;
• Dundee Pregnancy and Smoking Project (£54,702) - NHS Tayside: Dundee Local Health Care Co-operative/Community Health Partnership: individual smoking cessation counselling for pregnant women;
• CLASP (Cross Lanarkshire Action on Smoking in Pregnancy) (£55,460) - NHS Lanarkshire: individual smoking cessation counselling plus buddy support for pregnant women;
• QuitFit (£156,125) - NHS Fife: West Fife Local Health Care Co-operative/Community Health Partnership: individual smoking cessation counselling and exercise for people in a socio-economically deprived area;
• GUTSE (Give Up Tobacco Substitute Exercise) (£9,000) - Fife Council: Glenrothes area: group smoking cessation counselling and exercise for people with mental health problems or physical, sensory or learning disabilities;
• Smoking Cessation in Bowhouse ( HMP Kilmarnock) (£130,511) - NHS Ayrshire & Arran: individual (staff) and group (prisoner) smoking cessation counselling for staff and prisoners;
• Preventing Oral Cancer (£130,113) - Glasgow and Dundee Dental Hospitals: individual smoking cessation counselling for patients with oral lesions.

7.5 Four research-based projects were also funded:

• Developing a Culturally Valid Measure for the use of Tobacco and Related Substances by Ethnic Minorities (£56,965) - University of Edinburgh: specified ethnic minority groups;
• Smokey Joes (£70,282) - NHS Argyll & Clyde/Queen Margaret University College: a narrative-based therapeutic intervention for smoking cessation for use in a low-income community;
• Smoking Cessation for Older People (£19,213) - Glasgow Caledonian University: developing smoking cessation initiatives with older people (65+) and primary health care professionals;
• Smoking Cessation in The State Hospital (£40,000) - The State Hospitals Board for Scotland: smoking cessation for patients and staff within forensic mental health services within conditions of special security.

Achievements: ASH Scotland's Research Projects

7.6 It is important to recognise that ASH Scotland also has considerable experience of funding and supporting short-term projects relating to tobacco and health inequalities. This work started in 1996 with the Women, Low Income and Smoking Project ( WLISP) ⁴⁶, which was funded by the HEBS. This led to the development of the Tobacco and Inequalities (T&I) initiative. Phase 3 of the T&I Project (2003 - 2007) is a national community development project that aims to develop capacity and sustainability, as well as challenging and changing practice and policy. Funded to a total of almost £463,800 by the Scottish Executive Substance Misuse Division and NHS Health Scotland, its three target areas were:

• Mental health and well-being;
• Black & minority ethnic ( BME) communities;
• Older adults.

7.7 The most substantial element of Phase 3 was the small grants scheme, which made a total of £175,000 available to two waves of projects focusing on tobacco control in April 2005 (13 projects) and April 2006 (12 projects, including five from the first wave). Each project received between £1,000 and £15,000. Eight projects focused on mental health and well-being, four on BME communities, and eight on older adults. This initiative has been externally evaluated by academics from the Scottish Centre for Research on Social Justice at the University of Glasgow. The final report ⁴⁷ is due to be published early in 2008.

7.8 In addition, ASH Scotland has also funded a number of research projects focusing on working with young people. The most recent initiative has been the NHS Health Scotland/ ASH Scotland Young People Smoking and Cessation Pilot Programme. This programme funded eight pilot cessation projects which aimed to engage with young people wanting to quit smoking and to identify acceptable and potentially effective approaches to help them quit. The external evaluation of this work was published by NHS Health Scotland in June 2006. ⁴⁸

7.9 The T&I Project, the Youth Development projects and the PATH-funded projects share many similarities, with the overarching aim of working towards the dissemination of best practice in smoking cessation within the health inequalities field. These strands of work have become increasing inter-linked since 2005.

Achievements: Findings from the external evaluation of the PATH-funded projects

7.10 The report from an external evaluation of the PATH-funded projects ⁴⁹ was published in December 2006. The points below summarise the evaluation's findings relating to the extent to

which the PATH programme succeeded in identifying promising new ways of working with difficult-to-reach groups. It should be noted that some of the supported projects had not submitted their final reports when the external evaluation was undertaken.

7.11 Regarding better quit rates, the evaluation found that:

• On the basis of available figures on quit rates in the intervention projects, one project (QuitFit) showed clear promise. Its figures are comparable with quit rates elsewhere, despite high loss to follow-up and a high proportion of clients from deprived areas;
• No other intervention project showed any clear evidence of quit success better than comparable figures from England; indeed their quit rates were generally lower. The apparent lack of success of the other projects may be due in part to the lack of follow-up data rather than the ineffectiveness of the intervention.

7.12 Regarding stimulating more smokers to attempt quitting, the evaluation found that:

• In terms of attracting clients from difficult-to-reach groups, QuitFit, Stop for Life, Preventing Oral Cancer and CLASP all showed clear positive results. This is important, as it should result in increased population impact even if quit rates are modest;
• Services delivered in prison (Smoking Cessation in Bowhouse) also attracted strong demand, in line with experience in prisons elsewhere. In addition, a considerable proportion of patients in The State Hospital were involved in smoking cessation services;
• Those projects that planned to draw their clientele from referrals by professionals in mainstream health services, consulted with those professionals early in the planning stages, and involved them in the design of the referral system were successful in generating strong client interest;
• QuitFit achieved a very good flow of participants through an imaginative and eclectic mix of publicity methods and incentives. However, it is unclear which specific method worked well or whether it was a combination of these methods that resulted in the success.

13. In terms of developing new ways of interacting with clients, the evaluation found that:

• The Smokey Joes project centred around a relatively new style of intervention. The practitioners and funders of this intervention were enthusiastic about it. However, the information about success emerging directly as a result of the PATH-funded research project was limited and consequently it was not possible for the external evaluators to confirm or refute any claims of the effectiveness of the Smokey Joe approach;
• The experience of the projects targeted at pregnant women (i.e. Stop for Life, Dundee Smoking and Pregnancy Project, and CLASP) suggests that mainstream health professionals (e.g. midwives) are unlikely to deliver more than brief intervention in the course of their regular contacts with patients. It would appear that the most effective way to offer cessation support to pregnant women is through advisers who specialise in working with pregnant women, to whom midwives can refer. The idea of using 'buddies' to support quitting by pregnant women, as implemented by the CLASP project, was not found to be successful.

7.14 Regarding generating research results that will help improve future practice, the evaluation found that:

• Outcomes from the research into the development of culturally valid measures for ethnic minorities should make a significant contribution to good practice in understanding smoking prevalence and behaviours and in delivering and evaluating cessation support to these demographic groups. However, on its own this may not be considered as a 'way of working' but rather as a building block which others may use in developing their processes;
• Similarly, the project researching smoking cessation support for older people identified important issues to be incorporated into training and into cessation delivery programmes. These outcomes may also be considered as building blocks.

Subsequent achievements by the PATH-funded projects

7.15 The following material summarises the progress that has been made by the PATH supported projects since the publication of the external evaluation report. Of the eight service delivery projects, five have been incorporated into local service provision:

• QuitFit: This project has been allocated funding from NHS Fife until March 2008, at which point the situation will be re-assessed. The QuitFit project originally only covered west Fife but has now been extended to Dunfermline. The Fife-wide tobacco issues group has discussed QuitFit and is showing an interest in expanding the programme to other areas of Fife. There is also some interest from young people and the possibility of setting up a group for them is being investigated;
• Preventing Oral Cancer (Glasgow Dental School): Currently, three half days per week are being funded by NHS Greater Glasgow's Smoking Concerns service and further funding has also been received from other local sources. This research project is in the process of evolving and being 'mainstreamed' into a Stop Smoking service. The aim of this Stop Smoking service is to address the needs of those individuals most ready to quit smoking. The service will make use of both individual counselling and referral to local groups for the patients. This service started in August 2007 and is staffed for three sessions (half days) per week by the nurse (a specialist smoking cessation advisor) involved in the research study. Further analysis of the data will be undertaken, particularly with respect to cotinine ⁵⁰ and self-reported reductions in smoking levels;
• Stop for Life: This project has become a model of best practice. It has been adopted by NHS Lothian and NHS Fife Health Boards and is currently being explored by other Boards. It has also received a national award for its innovative approach;
• Smoking Cessation in Bowhouse ( HMP Kilmarnock): This has been adopted by NHS Ayrshire & Arran as part of their 'Fresh Air-shire' service;
• Smoking Cessation in The State Hospital: This project continued to be funded by PATH until 31 October 2007. It is anticipated that it will be retained as part of general health care provision at The State Hospital (which is a stand-alone NHS Health Board).

7.16 The remaining three service-based projects have not continued in their original form:

• CLASP: This project tried to provide a 'Buddy' system for pregnant women, but that aspect of the service was not successful. However, there is now an official pathway and local protocol for referring pregnant women to smoking cessation services available in the NHS Lanarkshire area, which are based at Wishaw General Hospital;
• GUTSE: This project failed to take off in any significant way in Glenrothes, and was quickly wound up by Fife Council. However, the fitness instructor who was involved in delivering the smoking cessation advice continues to do so in an ad hoc way with leisure centre users;
• Dundee Pregnancy and Smoking Project: This project was set up to review and develop the existing NHS Tayside pathway for pregnant smokers and to pilot a service aimed at helping them stop smoking. The protocol for referral was revised as a result, but the pilot service (which, in reality, was only provided by one Health Visitor) did not continue. However, the findings from the pilot did help inform the local action plan, and an incentive project, aimed at young pregnant women from deprived areas, is now running in Dundee.

7.17 The other three research-only projects were relatively successful:

• Developing a Culturally Valid Measure: This project succeeded in developing culturally valid questionnaires relating to tobacco use that can be used by health care workers with clients whose first language is not English;
• Smoking Cessation for Older People: This project aimed to gather qualitative data that would inform the development of training/education initiatives to help members of the primary care team provide older adults (65+ years) with information and advice to encourage them to stop smoking. These data helped provide recommendations for rolling out appropriate training, which is still to be developed further;
• Smokey Joes: The researchers sought to evaluate the process and impact of this new smoking cessation service, which uses a 'narrative therapy' approach to its work. The 'Smokey Joe' service itself was established prior to this research being undertaken, and continues to be delivered locally.

PATH achievements - dissemination event

7.18 PATH has also been responsible for supporting the dissemination of the findings of the work funded by the PATH Support Fund. A number of events have been held to deliver this task, the most recent of which was on 9 May 2007, when 55 delegates were invited from the supported projects, the Scottish Executive, PATH, ASH Scotland, NHS Scotland, Keep Well projects, and Health Board Smoking Cessation Co-ordinators. The day included a presentation by the external evaluators and presentations by most of the supported projects.

7.19 Evaluation Feedback Forms were completed by 21 delegates, who generally found the day to be informative, challenging and very relevant to their work. They also appreciated the networking and discussion opportunities offered by the event. They felt that they had learned a great deal about setting up and running such projects and also that different approaches may be needed in different situations.

Feedback from stakeholders and discussion

7.20 The interviews with stakeholders were used to:

• Request additional information from the 11 funded projects on progress, impacts and achievements since the publication of the external evaluation;
• Explore in more depth the potential impact of smoking cessation services on those experiencing health-related and other inequalities;
• Explore the effectiveness of the dissemination events (and any other types of dissemination used by PATH).

7.21 Regarding stakeholders' perceptions of general achievements of the funded projects:

• Overall, most respondents thought the supported projects were a good concept, because they focused on trying to find ways of working with hard-to-reach groups. ⁵¹ Several respondents from Health Boards (e.g. with responsibilities for public health and/or smoking cessation services) felt that the "easy" smoking cessation work has now been accomplished and the more challenging and complex work is about to start. This will require adopting new approaches - such as 'social marketing' ⁵² - to attract smokers from hard-to-reach groups;
• There sometimes seems to have been a conflict between "service" and "academic" views - those delivering the on-the-ground projects thought that PATH's focus was too academic, whilst the academics felt that some of the service-based projects lacked methodological rigour;
• The fact that the PATH grants for supported projects have been for relatively small amounts has meant that some projects have probably needed to find additional funding, which has subsequently led to local 'buy-in' and additional local funds directed at smoking cessation;
• One respondent felt that the PATH projects had made a positive difference by taking smoking cessation away from the medical centre;
• One interviewee commented that PATH funding has made it possible to undertake some innovative projects. However, another interviewee was concerned about the lack of practical outcomes from the supported projects and commented that it was unclear whether Health Boards have been able to implement any of the lessons learnt from them. Some stakeholders felt that all of the projects had provided valuable insights, even if these sometimes focused on what did not seem to work rather than on what did work. It was suggested that the fact that projects with similar foci (e.g. pregnant women; combining exercise with smoking cessation) tended to have significantly different degrees of success should be seen as a lesson in itself;
• Several respondents felt that the maximum funding period for projects of three years was too limited, given the time required to set up such projects (especially if this requires recruiting staff to the project) and to market them to potential referrers. Some of the funded stakeholders felt that they had underestimated the amount of (generally unfunded) senior management time needed by their supported project. Academic respondents commented that staff working on supported projects need funded time at the end of the project to prevent valuable learning and dissemination opportunities being lost. However, other stakeholders highlighted the importance of delivering results within a relatively short timescale, so that these can be disseminated and incorporated into training and services in other areas.

7.22 In terms of the project management and support provided by PATH:

• Many interviewees had considerable praise for PATH staff, as illustrated by the quotes below:

"They [i.e. PATH] have been very approachable and supportive. They haven't just acted as a funding body, they really did support our progress all the way through. They were very good at keeping in touch both in terms of informal discussions and coming to the locality to talk about issues and difficulties."

" PATH's key strength is their professionalism - both in terms of people and work undertaken. They have generated a good evidence base and their work has been carried out to a high standard."

"It has been a pleasure working with PATH. The people have been very responsive and supportive, showing great interest in and support for our project."

• However, the experience of others was less positive. Some dissatisfaction was expressed about the process of applying for funding. This was felt to be very cumbersome and time-consuming, especially by service providers with little or no experience of preparing submissions for such funds. However, one interviewee felt that lessons had been learnt, as the process used for applying for funding for the recent ASH Scotland funded T&I projects was much improved compared with that used for the PATH supported projects;
• Issues were also raised by some respondents around the support provided by PATH. Some felt that no real feedback had been provided on quality and also that support was sometimes spasmodic and inconsistent. One interviewee suggested that it would have been beneficial to have seen more monitoring and assistance, as there appeared to be a mismatch between the views and aspirations of practitioners in the field and researchers;
• It was also suggested that opportunities were missed at the outset to provide more support and advice on undertaking sound research (e.g. in terms of identifying suitable methodologies and outcome measures) and on the logistics of managing a service-based research project. Some respondents felt that PATH staff could have used some of the funds to buy this type of support from an academic organisation if they were unable to provide it themselves.

7.23 In terms of delivering value for money:

• There was conflicting feedback on whether or not the supported projects delivered value for money. For example, one person (from an academic background) felt that the projects (especially the service-based ones) had received very generous funding. However, a senior Health Promotion manager in one of the Health Boards that had received funding said that they would not bid in future for any similar research that was worth less than about £500k (or possibly even £1m) due to the high organisational overheads they had experienced associated with compiling bids and managing such projects;
• Another interviewee suggested that the money may have been better spent if it had been invested in, say, three well-funded projects addressing the same inequalities group but from different perspectives. He thought the supported projects lacked a cohesive sense of direction and took something of a 'scattergun' approach. However, he also recognised that such an approach enables several inequalities areas to receive simultaneous funding, which may be seen as being a more equitable approach.

7.24 Regarding stakeholders' views on disseminating the findings from the supported projects:

• The general consensus from those interviewed stakeholders who had attended the dissemination event in May 2007 was that it was a good opportunity to learn about the projects and to hear the external evaluators' report;
• However, the view was also expressed that the dissemination event merely allowed results to be shared with the other supported projects rather than with a wider audience;
• A number of respondents (including several from within PATH) stressed that it is important that the wider lessons from these (and the ASH Scotland) projects are incorporated into future training and developmental work. This must include learning from the 'softer' findings, such as ways of engaging hard-to-reach groups and supporting lapsed quitters (e.g. through motivational interviewing);
• Stakeholders also suggested that the findings from the supported projects (and other research projects managed by ASH Scotland) should be synthesized into a meaningful document that could be used to inform policy development more widely. Although presentations at conferences and similar events are important, it is also necessary to ensure that information is readily available via other sources. Such a document needs to be produced as soon as possible after the research has been completed, so that it has the greatest impact on service development and delivery.

7.25 In terms of future opportunities for similar work:

• Interviewees who had also been fundholders tended to feel that it would be good to see the continued involvement of PATH (and ASH Scotland) in supporting projects. There was a view that PATH staff will have learnt a considerable amount about administering projects, pulling things together, and helping people to manage projects and that it would be valuable to continue to have this expertise available. It was also felt that it would be useful to have PATH as an ongoing networking resource to help researchers avoid "re-inventing the wheel" by signposting them to relevant research or projects/evaluations undertaken elsewhere. Several stakeholders commented on how useful it was to be able to contact PATH for information about innovative work being undertaken with hard-to-reach groups in other parts of Scotland.

7.26 A variety of views were expressed about the types of project that PATH should support in the future:

• Several respondents (especially those from academic backgrounds) felt that it would be beneficial to link research elements to service delivery projects. Doing this would provide both stronger evidence and greater kudos;
• More work should be undertaken around smoking prevention (especially with young people);
• There is limited benefit from short-term projects as it is difficult to assess the impact and efficacy during this timeframe. If such projects are to be funded, then serious thought should be given to exit strategies before the projects are initiated;
• There appears to be a huge gap between smokers saying that they wanted help to give up and those who actually engaged with cessation services. Barriers need to be identified and explored and it was suggested that the NHS may not be the best agent to do this as there is currently a tendency for people to hide the fact that they are smoking from health care professionals. It would perhaps be more productive for smokers to hold discussions with "safe and trustworthy individuals" who are not health professionals (e.g. somebody from a voluntary organisation). PATH should therefore have the flexibility to fund projects put forward by health and voluntary sector partnerships.

7.27 Some stakeholders also suggested that there should be increased focus on utilizing the findings from the research projects and that methods for working out how findings affect practice, as well as methods for disseminating findings, should be put in place. It was also suggested that the most appropriate way to disseminate the findings of all of the supported projects is to use their lessons to inform the development of training courses focusing on engaging with specific hard-to-reach groups.

7.28 The following quote, which is taken from the external evaluation of pilot projects exploring how to encourage young people to stop smoking (Platt et al, 2006), illustrates how potential pitfalls could be avoided in the future:

"It is frustrating that there are so many questions that remain unanswered at the end of the programme. This is largely a consequence of the way that the programme was established and implemented. When similar programmes of demonstration or pilot projects are commissioned in the future, more thought should be given to the learning that is expected and therefore the appropriate design of the programme and the interface between intervention and research/evaluation. One possibility might be the development of a limited number of interventions, based on research evidence, needs assessment and practitioner expertise, which would first be refined using a theories of change approach, and subsequently rigorously 'tested' using appropriate (experimental or quasi-experimental) evaluation designs, incorporating intensive investigation of the implementation process."

7.29 An academic stakeholder suggested that in the future it will be important for researchers to consider how social marketing techniques could be used to develop ways of working to promote smoking prevention and cessation to whole communities rather than to specific sub-groups. For example, it is very difficult for a young person to stop smoking if other members of their family are heavy smokers. Older people may be encouraged to stop smoking in front of their grandchildren if this encouragement also comes from the children's parents. There seems to be considerable potential for exploring how community development work can contribute to reducing smoking rates, especially in socially and economically deprived areas, where rates tend to be especially high.

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