1. ARE SEXUAL HEALTH AND SMOKING CESSATION HEALTH IMPROVEMENT INTERVENTIONS DELIVERED WITH SENSITIVITY TO INEQUALITIES IN SCOTTISH HOSPITALS? Lorna Smith Senior Health Improvement Programme Officer: Health Promoting Health Service NHS Health Scotland 21 st IUHPE 2013 World Conference on Health Promotion August 25-29th Pattaya, Thailand

2. Session Outline Background Research Aims and Objectives Methodology Sexual Health Smoking Cessation Services Next Steps Further Information Every health care contact is a health improvement opportunity

3. Background Secondary care is a priority health promotion setting for the Scottish Government There is proportionately greater use of Scottish hospital services by patients from deprived communities, who are at increased risk of multiple health and social inequalities Models of delivery for health promotion interventions vary across Scottish hospitals The impact of such variation in practices is currently not well documented and/or understood, but anecdotal feedback indicates inconsistent opportunities to health improvement support

4. Research Aims and Objectives Research Aim: To better understand the models of delivery being applied to implement national health promotion actions in hospitals across Scotland, and assess the potential impact of this approach on those at increased risk of inequalities. Specific Objectives: Sexual health Map the models’ of delivery within termination services for all women to be provided with an effective method of contraception across all 11 Scottish hospital regions that provide terminations Describe the process for identifying those at increased risk of health inequalities and any additional support provided. Tobacco Map the models’ of delivery for hospital-based smoking cessation support across all 14 Scottish hospital regions Describe the process for identifying those at increased risk of health inequalities and any additional support provided.

5. Methodology Scoping Literature Review Relevant Scottish policy Demographics of a) Scottish smokers and b) those at risk of poor sexual health outcomes Existing evidence of inequality-sensitive practice for smoking cessation and provision of contraception Data-needs Analysis Scoping of national data on demographics of patients receiving health promotion intervention Qualitative research Interviews With hospital health promotion leads in addition to topic-specific lead for smoking cessation and sexual health and/or termination services. Review of local hospital protocol documentation (where available)

6. Sexual Health Scoping ‘Prior to discharge from termination services, all women should be provided with an effective method of contraception, including Long Acting Reversible Contraceptive (LARC), where appropriate.’ CEL (1) 2012 Action 18.6, Scottish Government Preventing unintended pregnancy supports multiple inequality-prevention actions directives within current Scottish policy. Longer-lasting contraception is a safe, effective and cost-effective intervention but remains used by only 1 in 25 Scottish women. The literature search provided no results for equality or inequality sensitive practice for long-acting contraceptive procedures delivered within hospital settings. National data is available on LARC rates by hospital region however no equality or inequality information can be extrapolated at present.

7. Sexual Health Results The majority of Scottish hospitals apply a whole-population approach to their sexual health improvement interventions. The provision of contraception is routinely considered within termination services, however inconsistencies are present in raising the issue and delivering the intervention which may increase inequalities. Patient information gathered to identify a risk of inequalities is often dependent on the route into the termination service. Overall, most staff working in termination services described their knowledge of health inequalities in relation to deprivation and poverty. A high number of staff in termination services reported that they lacked confidence to sensitively raise the topic of contraception and issues which increased patients risk of inequalities.

8. Sexual Health Results Summary Key issues Staff knowledge and training- contraceptive provision is limited by staff availability, expertise in inequalities and lack of leadership: Types of contraceptive they were able to offer No LARC trained staff at weekends Limited collaboration between termination clinical leads, primary care services and health promotion specialist Standardisation of protocols- inconsistency of delivery models and data recording across Scotland in termination services were present in: Whether requirement for additional support would be identified Method of contraceptive used by women Whether a contraceptive intervention was provided to a woman

9. Recommendations: Sexual Health Services A tailored training module for non-specialist sexual health staff Clearer pathways for referral and data management to ensure consistency of care and follow up. Development of an integrated care pathway Facilitate and develop national and local discussion on sexual health improvement interventions within hospitals

10. Smoking Cessation Scoping ‘Ensure dedicated specialist smoking cessation support is available within the hospital setting which is integrated with community-based cessation services.’ CEL (1) 2012 action 18.1, Scottish Government The relationship between smoking prevalence and health inequality is well- established throughout Scotland, with significant associations between socioeconomic disadvantage and rates of tobacco-attributable disease. Hospital settings provide an opportunity to target a large number of patients with smoking-attributed or smoking-exacerbated medical conditions. Previous studies focused on comparisons between the effectiveness of smoking cessation interventions across primary and secondary care, and within specific pathways such as cardiology or pregnancy. The national smoking cessation database records patient demographics on age, sex, ethnicity and employment status.

11. Smoking Cessation Results The majority of Scottish hospitals apply a whole-population approach to their smoking cessation service delivery. Access to smoking cessation support is not equitable or consistent across Scottish hospitals, or even within the same sites, which may increase inequalities. In the majority of cases, the patient information which would enable staff to identify patients at risk of inequality is either not requested or not recorded. Clinical staff training do not appear sufficiently trained with the skills and knowledge needed to effectively implement the integrated care pathway. Clinical staff were reported to feel uncomfortable in raising the issue of smoking with some patients based on individual judgments, or lack of understanding in the impact of smoking cessation services to improve quit-rate outcomes.

12. Smoking Cessation Results Summary Key issues Staff knowledge and training- smoking cessation support is limited by clinical staff knowledge of the cessation care pathway, and smoking cessation leads understanding of health inequalities: Smoking cessation leads assume they target inequalities because many hospital users are from areas of deprivation. Clinical staff were often a barrier to patient engagement, often through a lack of knowledge or understanding of nicotine addiction Standardisation of protocols- smoking cessation service delivery models, and adherence to them, across Scotland were dependent on: The specific hospital ward or department patients attended The specific health professionals they came into contact with Whether smoking status had been requested and/or recorded

13. Recommendations: Smoking Cessation Services Training programmes for ward staff in relation to smoking cessation should include information on health behaviour change, social determinants of health and brief interventions. Awareness-raising sessions with student nurses and junior doctors to encourage new practices within the hospital setting. Develop national and local support for consistent and equitable access to smoking cessation for all smokers attending hospital. Clearer pathways for referral and data management to ensure consistency of care and follow up.

14. Next Steps Disseminate findings to key stakeholders across Scotland. Influence future policy to consider targeted approaches where supported by evidence. Support evidence base on inequality-sensitive good practice. Encourage wider and consistent data collection on hospital patient demographics Consider impact of wider health promotion interventions within Scottish hospital on promoting equality and reducing inequality

15. Further information NHS Health Scotland National agency for reducing inequalities and health improvement: www.healthscotland.com National programme for hospitals health improvement action (HPHS): www.hphs.co.uk National programme for sexual health and HIV: www.healthscotland.com/wishh National programme for tobacco: www.healthscotland.com/topics/health/tobacco/ Research Steering Group:  Lorna Smith- (Senior Health Improvement Programme Officer: HPHS)  Ruth Johnston (Senior Health Improvement Programme Officer: Sexual Health and HIV)  Jane Oliver (Health Improvement Programme Officer: Tobacco)  Rebecca Sludden (Research Officer)  Dionne Mackison (Public Health Advisor)  Shirley Windsor (Health Improvement Programme Manager: Sexual Health)

16. References CEL (01) 2012: Health promoting health service: action in hospital settings, Directorate for Chief Medical Officer, Public Health and Sport Scottish Government, Edinburgh, 2012. ASH, 2011. ASH Scotland Tobacco and inequalities March 2011. Macintyre, 2007. Inequalities in health in Scotland: what are they and what can we do about them? Occasional Paper No. 17, Oct 23, 2007. Medical Research Council Marmot, 2010. Marmot Review report - 'Fair Society, Healthy Lives’. Moore, F. 2011. HPHS briefing Smoking Cessation - 2011 edition NHS Health Scotland, 2009.Your guide to long lasting contraceptive. Taulbut et. al, 2008. Tobacco smoking in Scotland: an epidemiology briefing. NHS Health Scotland. Contact Lorna Smith Senior Health Improvement Programme Officer, NHS Health Scotland Email: lornasmith1@nhs.net