An Intervention to Promote Smoke free Policy

Development in Rural Kentucky

Ellen Hahn, DNS, RN, Principal InvestigatorUniversity of Kentucky College of Nursing

National Heart, Lung, and Blood Institute (NHLBI)RO1 HL086450

October 8, 2008

PAR-06-039 Dissemination and Implementation Research in Health

Study Purpose To test the effects of a community

intervention on smoke-free policy outcomes in rural underserved communities. To accelerate the ‘diffusion-of-innovations curve’

in rural communities through tailored, evidence-based dissemination and implementation efforts.

Long-term Goal

To develop a best practices framework for disseminating the information on the state of scientific knowledge about the effects of secondhand smoke and smoke-free laws and implementing effective community policy change and maintenance strategies in rural underserved communities.

Background Enacting smoke-free laws typically depends

on the readiness of local people who have the greatest and most sustainable impact in solving local problems.

Rural residents more likely to be exposed to secondhand smoke than those living in urban areas, reflecting a major rural-urban disparity in smoke-free laws.

Kentucky Communities with 100% Smoke-free Workplace* and/or Public Place Ordinances or Regulations

Lexington Georgetown* Letcher County Morehead* Frankfort Ashland* Elizabethtown* Paducah Hardin County*

(unincorporated areas) Madison County* Louisville* Danville*

4/27/04 10/1/05 7/1/06 8/1/06 8/22/06 10/1/06 12/1/06 4/1/07 4/1/07

6/11/07 7/1/07 and 1/11/08 8/8/08

Primary Hypotheses Controlling for contextual factors:

H1: The overall change in stage of readiness for smoke-free policy will be greater for Treatment than Control communities;

H2: Media coverage will be more favorable toward smoke-free environments in Treatment than Control communities; and

H3: Treatment communities will be more likely than Control communities to demonstrate initial, intermediate, and final smoke-free policy outcomes.

Secondary Aims Test the effects of community readiness

assessment on stage of community readiness and smoke-free policy outcomes;

Evaluate the implementation of the intervention; and

Test for the influence of secular trends in diminishing the difference between Treatment and Control communities in change over time.

Research Design

Treatment O1 X1X2 O2 X1X2 O3 X1X2 O4 X1X2 O5 X1

Control I O1 X1 O2 X1 O3 X1 O4 X1 O5 X1

Control II O1 O2 O3 O4 O5 X1

O = Community observations: print media evaluation, smoke-free policy outcomes, secular trends, contextual variablesX1 = Intervention component I: Assessment of stage of community readiness.X2 = Intervention component II: Stage-specific, tailored strategies.

Study Counties Treatment (n = 22)

Readiness Assessment Annually and Intervention Control I (n = 8)

Readiness Assessment Annually Control II (n = 10)

Readiness Assessment Year 5 Only

*Note. The PRC CAB is taking a leadership role in Perry County, an Eastern Kentucky county.

Study Intervention

Component I: Stage of Readiness

• Unawareness• Vague Awareness• Pre-planning• Preparation• Initiation• Endorsement

Component II:Stage-specific Tailored Strategies

• Translation and dissemination of knowledge

• Building capacity for smoke-free policy• Building demand for smoke-free policy

Figure 5: Study Intervention Components

Component 1: Assessment of Community Readiness

Existing smoke-free policies

Community climate

Political climate

Resources

Community knowledge about

SHS & existing efforts

Leadership

Translation & Dissemination of Science Policymaker Assessments Public Opinion Studies Air Quality Studies Smoke-free Toolkit

Building Capacity Coalition Building Building Organizational Capacity Basic Legal Information Growing Legislative Champions Training on local policymaking process Leveraging funds (each county awarded

mini-grant, $2500 per year x 5 years)

Building Demand

Build on the existing rural infrastructure Media advocacy Advocacy: grassroots and grasstops Branding a smoke-free campaign

Primary Measures Community Readiness

3-5 Key Informants (community advocates) Mayors and County Judge Executives

Print Media Evaluation NewsClipz

Smoke-free Outcomes No policy outcomes (0); work group or resolution

(1); draft ordinance (2); ordinance enacted (3); comprehensive ordinance (4)

Project StaffCommunity Advisors

◦ Shevawn Akers/Heather Robertson◦ Carol Riker◦ Brenda Vestal◦ Carol Whipple/Sarah Cavendish

Community Liaisons◦ Baretta Casey, MD, Director, UK Center for Rural

Health◦ Peggy Lewis, State Office of Rural Health◦ James Rousey, Public Health Director, Madison

County Health Department

Project Consultants Judy Owens, JD, Legal Consultant

Collaborates with the Tobacco Control Legal Consortium at the University of Minnesota.

Todd A. Warnick, MA, MHA, CADC, Smoke-free Campaign Consultant

Key Support Staff Kathy Begley, Data Management Coordinator Karen Arrowood, Research Assistant Amanda Fallin, Research Associate Erin Lee, Project Assistant Kiyoung Lee, Assistant Professor and Environmental

Scientist, UK College of Public Health Mary Kay Rayens, Professor and Mei Zhang, Data

Analyst Heather Robertson, Manager, Clean Indoor Air

Partnership

5-Year Project Summary Readiness Interviews (Spring/Summer)

Advocates Elected Officials (County Judge Executives and Mayors)

Readiness Reports to Communities (September) Community Advisors serve communities as they

develop/revise a tailored roadmap for next steps or review existing plans (ongoing)

Community and Community Advisor prepare scope of work for mini-grant contract with UK (annually)

Community advocates use roadmap to take action based on stage of readiness (ongoing, regular contact with Community Advisor as needed)

What Have We Learned? The community with the highest overall

baseline readiness score at baseline (Year 1) enacted a comprehensive smoke-free ordinance in Year 2.

Communities with more Capacity for tobacco control (i.e., leadership, numbers of personnel committed to tobacco control as well as linkages between key agencies and advocacy groups) are more ready for smoke-free policy.

Communities that report more Efforts related to tobacco control (i.e., time spent on media advocacy, training and technical assistance, policy advocacy) are more ready for smoke-free policy.

Readiness dimension TreatmentMean (SD)

(n = 22)

Control IMean (SD)

(n = 8)

t-test (p-value)

Leadership Political climateCommunity climate ResourcesExisting smoke-free policiesCommunity knowledgeOverall readiness

0.51 (.09)0.56 (.15)0.44 (.09)0.61 (.08)0.42 (.13)0.40 (.17)2.94 (.52)

0.42 (.09)0.55 (.08)0.43 (.08)0.55 (.08)0.35 (.17)0.27 (.09)2.58 (.31)

2.2 (.03)0.1 (1.0)0.4 (.7)1.7 (.1)1.2 (.2)

2.1 (.04)1.8 (.08)

Average readiness scores by group, with comparisons based on two-sample t-tests for means (N = 30)

Note. The community with the highest baseline readiness score enacted a comprehensive smoke-free ordinance in Year 2.

Lessons Learned Tailoring interventions

Popular, low-cost communication channels (e.g., weekly shopper bulletins and weekend ‘trader’ radio shows)

Opposition tactics (e.g., ‘little tobacco’) Air quality monitoring

Special concerns in small communities where everyone knows everyone

Concerns that businesses do not have advance notice when monitoring conducted

Summary The Rural Smoke-free Communities

Project assists rural partners and acts as a value-added resource as they work toward implementing comprehensive smoke-free policies in their communities.

We believe that successfully moving toward smoke-free policy goals needs to be a carefully planned, community driven effort by committed local advocates.