Implementing a Second-Hand Smoke Reduction Intervention for Head Start Preschool Students Cynthia Rand, Ph.D Michelle Eakin, Ph.D. Funded by HL 092901
Health Impact of Secondhand Smoke Exposure (SHSe) on Children • SHSe is causally associated with the development of a variety of pediatric respiratory tract problems, including asthma, 2 respiratory syncytial virus (RSV), middle ear disease, pneumonia and bronchitis, upper respiratory tract infections, as well as Sudden Infant Death Syndrome • For every 100,000 U.S. children, at least 1000 excess respiratory infections and 500 excess hospitalizations have been attributed to SHSe • Annual healthcare expenditure directly related to SHSe is approximately $5 billion with another $5 billion in indirect expenses. • Upwards of 40% of all U.S. children are exposed to SHS, with low- income minority children having rates of exposure up to 68%, suggesting that the risks of SHS exposure are widespread.
Interventions for Children Multiple levels Partnerships Multiple Dimensions Clark 2009 JACI 3
Steps of Translation www.re-aim.org
RE-AIM Framework Description REACH Overall proportion of people who received intervention over total eligible population EFFECTIVENESS Effectiveness of intervention to improve health outcomes ADOPTION Number of programs who have adopted intervention into regular practice IMPLEMENTATION Processes to implement intervention within each unique settings. May require changing intervention, staff training, clinic flow MAINTENANCE Number of programs who sustain intervention after research program is completed Glasgow et al 2004 AJPH
Dissemination and Implementation • Interventions need to include individual and organizational level components • Best integrated within existing structures to serve public in community based research • Target organizations that serve at risk populations to reduce health disparities
Baltimore City Head Start Partnership • 11 Head Start Programs • Over 50 sites • 500 Staff members – 100 FSC – 400 Teachers • 3500 Children 7
Baltimore City Head Start • 25-30% of children diagnosis of asthma • 25-30% of children exposed to secondhand smoke • 95% African American • 100% Low-income
Office of Head Start In 2007 EPA and the Office of Head Start announced a Memorandum of Understanding • Cooperative activities to promote awareness • Distribute effective strategies • Lacks support to implement
Efficacious Interventions to Reduce SHS exposure • Systematic review has found behavioral interventions to be most efficacious in reducing SHSe • Motivational Interviewing – 3 studies demonstrated efficacious – Not routinely implemented in community settings Rosen 2012. Pediatrics; 129 :141 -152
Study Aims • Evaluate the effectiveness of Motivational Interviewing + Head Start education in reducing child SHSe compared to Head Start education alone • Evaluate implementation of interventions in Head Start using RE-AIM framework
RCT Design • Families with 1+ smoker in the home recruited from Head Start • Assessments completed at Baseline, 3-, 6- , and 12- months – 2 home visits at each time point – Air nicotine monitoring for 7 days – 2 child salivary cotinine 7 days apart – Caregiver survey • Randomized to MI + Education or Education Alone after Baseline
Screening Procedures • Screening survey disseminated by HS staff • Option to not complete form but still be counted – Have to opt-in to be contacted about the study • HS Staff compensation – $50 to teacher if 80% of class returns screener by due date – $50 to FSC if all assigned classrooms cumulatively meet 80% completion
REACH 11,936 Children enrolled in Head Start 10,523 (86%) Children screened 2910 (28%) Reported a smoker in the home 1289(45%) Interested in research 350 (27%) Enrolled in intervention study
Participants n = 330 • 93% African American children • 50% female children • 73% household income <$30,000 • 61% Caregiver HS graduate or less • 66% Caregiver smokes
Prevalence of SHS exposure 50 Smoker in Home 40 28% 30 18% 20 10 0 ≥1 Smoker in home CDC Data 2007-08 Baltimore City Head Start 2007-11 Head Start data based on screening 10,428 children
Measures • Air Nicotine • Salivary Cotinine • Prevalence of Home Smoking Bans
Head Start Education • Smoke-free days • Staff education • Lesson plans • Health Fairs • Health Advisory Meetings
Implementation Strategies • Offer CE credits • Universal Screening • Adapted Education program for each HS site • Website and resources available • Awareness Building Activities • Staff Engagement
Key Principles of Motivational Interviewing • D evelop Discrepancy • E xpress Empathy • A mplify Ambivalence • R oll with Resistance • S upport Self Efficacy Goal is to identify, examine and resolve ambivalence about change
MI + Education • All components of Head Start Education • 4 sessions of MI – Provide feedback on cotinine – Decisional Balance – Motivation/confidence ladder – Training on talking to family members – Support self-efficacy – Smoking cessation, if applicable
Cotinine Feedback High Exposure Your child was exposed to as much smoke as if (above 4.5 ng/ml) they were a smoker themselves. Moderate Exposure Your child was exposed to moderate levels of (between 2.0 and smoke, as if they smoked a few cigarettes themselves. 4.5 ng/ml) Low Exposure Your child was exposed to low levels of cigarette (between 0.05 and 2 smoke, but still much more than the child of a non- ng/ml) smoker. Very Low Exposure Your child had very low exposure to smoke. It is (less than 0.05 great that your child is kept away from smoke. Keep ng/ml) it up! No Exposure Your child had no exposure to smoke. It is great that (0 ng/ml) your child is kept away from smoke. Keep it up!
Effectiveness: Air Nicotine Group * time P <0.05 1 0.9 0.8 Air Nicotine Levels 0.7 0.6 Baseline 0.5 3 month 0.4 6 month 0.3 12 month 0.2 0.1 0 MI + Education Education alone
Effectiveness: Prevalence of Home Smoking Bans (HSB) Group * Time p <0.05 45 40 % families with a HSB 35 30 Baseline 25 3 month 20 6 month 15 12 month 10 5 0 MI + Education Education alone
Post hoc analysis of successful implementation of HSB (n = 88) Air Nicotine Salivary Cotinine P <0.01 0.8 4 P <0.01 0.7 3.5 0.6 3 0.5 2.5 Baseline Baseline 0.4 2 3 month 3 month 0.3 6 month 1.5 6 month 0.2 1 0.1 0.5 0 0 MI+Educ MI+Educ
Effectiveness: Intent-To-Treat • Overall ITT – lower air nicotine at 12 months in MI + education group – Increase in prevalence of HSB at 3 months in MI + education group • Post Hoc Analyses – Families who implemented HSB had sig. lower cotinine and nicotine
Adoption: Head Start Staff Education I do not know how to talk about SHS with families Talking about SHS with families is part of my job Educational materials about SHS Pre available at Head Start Education Staff attended a secondhand smoke education program Post Education Do you talk to parents about their child's exposure to SHS 0 20 40 60 80 Percent Endorsed * p<0.05 for all items
Implementation: Community Based Research • Staff witnessed a homicide en route to a home visit • Changed protocol from home to phone intervention visits
Implementation: Home versus Phone • 83 families were randomized to receive 2 home sessions and 3 phone sessions • 82 families received 5 phone sessions • Families in the phone only condition had significantly lower air nicotine and greater prevalence of HSB at 3- and 12- months • The phone only group had a significantly higher completion rate (54% to 33%)
Maintenance • 0 Head Start Programs have scheduled SHS education program • 29% of children still live with smokers • 80% of families report having a home smoking ban – Increased from 70% at baseline
Intervention Evaluation using RE-AIM Framework Outcome REACH 12% enrolled in study among all children with SHS; EFFECTIVENESS Families in the MI+ Educ group had a 15% increase in HSB and decrease in air-nicotine at 12 months and families with HSB had lower nicotine and cotinine ADOPTION 83% of HS programs participated in SHS training. Staff reported significant improvement in knowledge, beliefs and comfort talking about SHS. IMPLEMENTATION Only 33% completed 4 sessions Change in home vs. phone showed phone delivery had better completion rate and treatment effect Fidelity monitoring 2-3X/month MAINTENANCE 0 Head Start sites scheduled education programs after intervention period
Challenges to Implementation • Limited community resources – Time – Money – Staff • Low uptake of intervention • Competing demands on family
Qualitative Analyses of Unique Barriers for Intervention • Transcribed random sample of 50 intervention session tapes • 2 coders analyzed transcripts to identify major themes using Grounded Theory Approach • Identify barriers and facilitators for implementing a home smoking ban
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