Design
The changes in perceptions of support for smokefree hospital entrances study has a repeat cross sectional design. Survey questions were asked before and after the implementation of a public health social norms campaign (see supplementary file for survey questions). The campaign was designed to reduce levels of misperceptions surrounding support for smokefree hospital entrances amongst hospital patients, visitors, and staff. The survey investigated self-reported actual and perceived social norms associated with smoking in hospital entrances and on hospital grounds. Serafin et al. reported the results of the secondary analysis of the free text responses provided by participants [15].
Setting
Pinderfields Hospital is a NHS hospital based in Wakefield (United Kingdom). It is part of The Mid Yorkshire Hospitals NHS Trust that provides community, acute (hospital-based treatment) and specialist health services to around half a million people living in the Wakefield and North Kirklees areas. The hospital is approximately one mile from Wakefield City Centre. The hospital has one main entrance used by staff, patients, and visitors. The double-door entrance is step-free with a canopy that offers some protection from the weather. In 2006 Pinderfields Hospital implemented a smokefree hospital grounds policy that meant smoking was no longer permitted anywhere on the ground. This included at the entrance, in car parks, on paths or and on roads. The sign at the road entrance to the hospital included the words ‘Welcome to a smoke-free hospital’ and the glass front near the entrance to the hospital building displayed a no-smoking icon. In 2012 a minority of staff, patients, and visitors continued to smoke on hospital grounds. Staff and patients complained of smoke entering through windows opened above the entrance. The Mid-Yorkshire Hospitals NHS Trust launched the social media campaign in an effort to make the hospital grounds completely smokefree. The timing of the activity was as follows: before campaign survey 10th–18th September 2012, implementation of campaign 26th November-17th December 2012, after campaign survey 17th – 21st December 2012.
Participants
All hospital patients, visitors, and staff on the premises of Pinderfields hospital during data collection periods were eligible to participate. The sample was one of convenience. One thousand individuals were approached. In total n = 963 questionnaires were returned (96% return rate). Of these 23 were excluded (n = 20 age < 18 years, n = 3 < 50% completion). Therefore n = 940 completed questionnaires were eligible for inclusion in the analysis (i.e. 94% response rate). The current analysis incudes data collected from n = 481 participants before implementing the campaign (n = 164 patients, n = 143 hospital visitors, n = 163 hospital staff, unknown/other n = 11), and data collected from n = 459 participants after the campaign (n = 157 patients, n = 143 hospital visitors, n = 156 hospital staff, other n = 3).
Ethics
This study received approval from Research and Development (R&D) (Mid Yorkshire NHS Trust). The Trust approved the study as an audit and evaluation of smoking behaviour on Pinderfields hospital grounds. Permissions were granted via NHS Wakefield.
All participants were provided with information to enable informed consent. Completion and return of the pen and paper questionnaire indicated consent. Individuals had the right to refuse to participate. All questionnaires were completed anonymously and once surveys were returned it was not possible for data to be withdrawn.
Procedure
Convenience sampling was undertaken. Data collection was organised to ensure that all accessible areas of the hospital building and grounds were covered. Paper surveys were distributed throughout the hospital and grounds (e.g. reception areas, hospital wards, outpatient service waiting areas, administrative staff areas, staff coffee rooms, canteen areas, hospital shuttle bus queue). Questionnaires were distributed face-to-face by a researcher and self-completed by the participant. Where possible questionnaires were returned to/collected by the researcher. Where this was not possible participants were asked to return completed questionnaires to reception. In total 1000 surveys were distributed and 940 (94%) were completed, returned, and included in the current analysis. The incentive for the completion and return of each survey was a donation of £1 to a local charity paid on their behalf. Three choices of charity were given: The Mid Yorkshire Hospitals NHS Trust Charitable Fund, Wakefield Hospice and Macmillan Nurses.
Main outcomes measures
The main outcome measure was the difference between perceived and reported levels of support for smokefree hospital entrances. Perceived and reported levels of support were measured using questions adapted from existing social norms approach surveys. Participants were asked to indicate their level of agreement (5 point Likert scale, strongly agree to strongly disagree) with the following statements: ‘Hospital patients should not smoke in hospital building entrances’; ‘Hospital staff should not smoke in hospital building entrances’; ‘Visitors should not smoke in hospital building entrances’. Participants were then asked to estimate how many people (hospital patients, hospital staff, and hospital visitors) agree that ‘Pinderfields Hospital entrances should be a place where people don’t smoke’; responses were recorded using a visual analogue scale (no patients thru to all patients). Secondary outcome measures included perceived and reported behaviour (i.e. smoking in hospital entrances and/or grounds). The measure of self-reported behaviour asked participants to indicate the statement that best described them. Their choice of statements was: I am a non-smoker; I am a smoker but do not smoke anywhere on hospital grounds; I do not smoke in the entrances to the hospital building, but I do/would smoke elsewhere on the grounds; I only smoke in the entrances to the hospital building, but would not smoke elsewhere on the grounds; I smoke on hospital grounds, this includes in entrances to the hospital building (see Additional file 1 for a copy of the questionnaire).
Intervention
Returned pre-campaign questionnaires were used to derive the marketing message. In total 485 questionnaires provided self-reported data on whether or not participants smoked in the hospital entrance. Of these 478 (i.e. 98.6%) reported not smoking in hospital entrances. The intervention message was created by a marketing agency. For the purposes of the campaign a decision was made to keep the language as simple as possible and to avoid academic jargon. The campaign message did not therefore make a distinction between self-reported and actual behaviour. Social norms marketing strategies were used to disseminate the message that ‘99% of patients, staff, and visitors keep our hospital entrance free from cigarette smoke’. The message was displayed and promoted using a variety of print media displayed throughout the hospital. The print-media and hospital locations were chosen to be highly visible to the target audience of staff, visitors, and patients in areas of high footfall and around the hospital. Print media included: expo and pull up banners, posters, wobblers, stickers, pins, canteen napkins and tray lining, café barriers, wraps on bollards outside the hospital entrance, peelable window stickers and leaflets on staff payslips (see Fig. 1 for examples).
Analysis
Analysis of Variance (ANOVA) was used to examine the effects of time (before vs. after campaign) on perceptions of smokefree entrance behaviour and perceptions of attitudes towards smokefree entrances of staff, patients, and visitors. ANOVA was deemed appropriate for this ordinal data as studies have shown that Visual Analogue Scales have interval and ratio properties and so can be treated as numerical [24]. ANOVA was also used to examine the effects of time (before vs. after campaign) on self-reported smoking behaviour in the entrances by staff, patients, and visitors.