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,2respiratory 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

3

Clark 2009 JACI

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

18%

28%

0

10

20

30

40

50

≥1 Smoker in home

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

• Develop Discrepancy • Express Empathy • Amplify Ambivalence • Roll with Resistance • Support 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 (above 4.5 ng/ml)

Your child was exposed to as much smoke as if they were a smoker themselves.

Moderate Exposure (between 2.0 and

4.5 ng/ml)

Your child was exposed to moderate levels of smoke, as if they smoked a few cigarettes themselves.

Low Exposure (between 0.05 and 2

ng/ml)

Your child was exposed to low levels of cigarette smoke, but still much more than the child of a non-smoker.

Very Low Exposure (less than 0.05

ng/ml)

Your child had very low exposure to smoke. It is great that your child is kept away from smoke. Keep it up!

No Exposure (0 ng/ml)

Your child had no exposure to smoke. It is great that your child is kept away from smoke. Keep it up!

Effectiveness: Air Nicotine

00.10.20.30.40.50.60.70.80.9

1

MI + Education Education alone

Air N

icot

ine

Leve

ls

Baseline3 month6 month12 month

Group * time P <0.05

0

5

10

15

20

25

30

35

40

45

MI + Education Education alone

% fa

mili

es w

ith a

HSB

Baseline3 month6 month12 month

Effectiveness: Prevalence of Home Smoking Bans (HSB)

Group * Time p <0.05

Post hoc analysis of successful implementation of HSB (n = 88) Air Nicotine

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

MI+Educ

Baseline3 month6 month

Salivary Cotinine

0

0.5

1

1.5

2

2.5

3

3.5

4

MI+Educ

Baseline3 month6 month

P <0.01 P <0.01

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

0 20 40 60 80

Do you talk to parents about theirchild's exposure to SHS

Staff attended a secondhand smokeeducation program

Educational materials about SHSavailable at Head Start

Talking about SHS with families ispart of my job

I do not know how to talk about SHSwith families

PreEducation

PostEducation

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

Barriers to SHS reduction

Child follows parent • “it's like a moth to a flame, as soon as I light a cigarette he will come

flying in the room.”

Neighborhood Safety • “They don't bother you too much, but I just don't like to see all what's

going on out there. I just don't like it.” • “They selling out the house, they do all kinds of stuff over there.”

Police Involvement • “Cause I see the police come walk their beat, ask questions, I don't

want to get involved so I just basically stay in the house.” • “If the police see a lot of people in the front, then they bothering us.”

Weather • “Cuz it's getting colder so probably more smoking we will do in the

house because of the weather.”

Facilitators of SHS Reduction

Physician Support • “And then my doctor's talking to me about it.”

• “She was telling me, to just try to take it slow, don't try to do cold turkey like I've been doing in the past.”

• “Cause my doctor put me on the patch. I couldn't do this without it.”

Cost • “I don't care how stressed out I be, plus it cost too much.” • “The money that I spend, I can spend on something else.”

Be a Good Parent • “He feel like he did a great step, he took a great step for his family.” • “Cause I feel like I failed as a parent with my first son because now I

see by me smoking so many years he picked up the habit and I'm trying to avoid that for the other 3.”

Tailor Interventions for Population

• Difficult for a caregiver to leave a young child to smoke outside

• Inner city outdoor environments are challenging – Police harassment – Physical safety – Annoyance from neighbors (chipping)

• Family Dynamics

Implications

• MI is effective in reducing SHSe in Head start children

• Need to develop different strategies to engage more families

• Reduction to SHS exposure needs to be addressed across multiple levels to increase reach and overall public health

• Need to develop mechanism for sustaining interventions

Acknowledgements

Principal Investigator Cynthia Rand, Ph.D Co-PI, Michelle Eakin, Ph.D. Co-Investigators Kristin Riekert, Ph.D. Belinda Borrelli, Ph.D. Arlene Butz, ScD. Mel Hovell, Ph.D. Mandeep Jassal, MD

Statisticians Andrew Bilderback Angela Green Baltimore City Head Start Johns Hopkins Adherence Research Center