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Bridging Community and Medical Practice to Enhance Smoking Cessation for Prenatal Women and to Induce Tobacco Norm Changes in a Rural County

State: NY Type: Model Practice Year: 2018

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Oswego County Health Department, Oswego, New York
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Bridging Community and Medical Practice to Enhance Smoking Cessation for Prenatal Women and to Induce Tobacco Norm Changes in a Rural County
Oswego County is located on the southeast shore of Lake Ontario in upstate New York, occupying 951 square miles, slightly larger than the State of Rhode Island, with a population of 120,000. Sixty-one percent of the population lives in rural areas. Socioeconomically, Oswego County experiences difficulties in recent decades, such as a higher than the state and national unemployment rate and poverty rate. In 2013, more than a quarter of children younger than 18-year-old in the county lived under the federal poverty level. For many years, high smoking rates have been a known public health issue in the county. The adult smoking rate was among the highest in the state in the past and became one of the key factors that made the county's health behavior indicators poor in the National County Health Rankings. Tobacco use results in cancer, heart disease, and chronic lower respiratory disease the top three leading causes of death in the county. High adult smoking rates also affect other population's smoking habits. A survey of local schools found 20% of 9-12 grade students smoke at least a couple of times a month. The smoking rate was high among pregnant women as well. All the while, the county's limited tobacco cessation resources were scattered in different agencies. This application is to present an intersectoral partnership that integrates different agencies and resources to support a clinical intervention at the local level to address tobacco issues in the community. The partners include agencies from public health, social services, higher education, and medical practice. By bringing the disparate public and private entities together, local anti-tobacco forces and resources jointly focus on the target population with a shared vision. The partners hold a high goal: To change the community norm regarding tobacco by collaboratively addressing pregnant women's social and financial needs to quit smoking successfully and by empowering them to make healthy choices. The centerpiece of the program is the clinical intervention in a private-owned obstetric and gynecologic clinic. This clinic is the only one of its kind located in the county and serves about half of obstetric patients in the county. The other partners fill the identified gaps in clinical intervention and support the pregnant smokers' needs. Specifically, training for clinicians to update their knowledge and skills was delivered, and screening tools were developed before the program was rolled out; incentives and other supports for patients have been provided since the program started; and program coordination and progress review is carried on in an ongoing basis. The partner agencies meet regularly. The partners set measurable objectives for the program as follows: Educate all obstetric patients about health risks of first- and second-hand smoke; Enroll 30% of smoking pregnant women in the clinic into the program at any point in time, and serve more patients with the public insurance than those with the private insurance; Retain 30% of enrollees who stopped smoking during their pregnancy; and Strive for 30% of the quit women during pregnancy to remain smoke-free through the baby's first birthday. Since the program was rolled out in the summer of 2015 to the summer of 2017, it has met the objectives of the program. The program consistently shows the following outcomes by its monthly review and assessment: reached 100% obstetric patients about health risks of first- and second-hand smoke; enrolled 30% of smoking pregnant women in the clinic in the program; retained 75% or above of program participants tobacco free through their pregnancy; achieved 47% of the quit women during pregnancy to remain smoke-free through the first year after baby's first birthday; and the program has served more women with the public insurance (79%) than with the private insurance (21%). The above outcomes came from data collected in the program at the Oswego County OB/GYN. Other data collected by some registry and survey also supported the above findings and revealed that the community norm toward tobacco is changing. Accumulated evidence indicates the program is an effective and powerful program. The program continues at the original practice and is expanding its services to more maternal and child health care sites in the county. The program is successful because of: An innovative intersectoral integration of public health, social services, medical practice, and higher education at the local level; and A true partnership with a clear goal and measurable objectives, unified strength and concerted efforts, regular meetings and assessments, and collective decision-making process. Website: www.oswegocounty.com/info/news/2016/092316-1.html
Primarily due to the high adult smoking rates, Oswego County was ranked the last in Health Behaviors” in all 62 counties in the State of New York by the Robert Wood Johnson Foundation from 2011-2015. For example, Oswego County's adult smoking rate was an alarming 33% while the state average rate was 18% in 2013. High prevalence of smoking adults caused other populations to follow. A local student survey found close to two-thirds of high school student smokers came from a household with at least one parent/guardian who smokes. Most of these youth reported the first-time smoking at the age between 12 to16 years old. A regional Perinatal Data Report found the rate of smoking during pregnancy in Oswego County higher than the surrounding counties and the state average. Among pregnant women in Oswego County, 26% continued to smoke during pregnancy in 2013. Local observations indicated that the adult smoking population was concentrated in the population with lower educational attainment and economic status. Most of the current smokers were those who had not finished college and in households with less than $50,000 annual incomes. A further investigation indicated the burden of smoking among pregnant women was tilted socioeconomically. More than 40% of pregnant women with Medicaid smoked while only less than 10% with private insurances, an obvious income-based health disparity. The high smoking rates exerted high health burdens on the community. While the State had its average annual age-adjusted lung cancer death rate just above 40 per 100,000 population between 2009-2013, Oswego was one of the only three counties with its lung cancer death rate above 60 per 100,000 population. Moreover, an ongoing multi-year community survey showed that the community as a whole had a lower awareness that tobacco's health risks compared to counties in the region (Community tobacco survey of adult residents of Oswego County, by Joel LeLone Consulting, Watertown, NY, 2008, 2010, 2014, and 2017). In early 2014, using the revelation of Oswego County by the National County Health Rankings, the county health department started to reach out to local agencies that dealt with tobacco issues and some educational institutes. By studying the data, leaders of these agencies and institutes realized the severity of tobacco issues in the county and were determined to work together in innovative ways to address the issues. Historically, public health, social services, and medical care share some common goals but work independently in addressing community's and individual's health and wellbeing. Generally, both public health and medical care aim at improving health but public health works at the population level while medical care at the individual level; both medical care and social services work at the individual level, but social services include medical care and go well beyond, including housing, transportation, nutrition, etc.; both public health and social services focus on the community, but public health stresses on prevention and social services are good at intervention. Specifically, medical interventions for tobacco cessation have higher efficacy but low reach, while public health has higher reach but lower efficacy; when many smokers face social and economic challenges in reaching their personal health goals, social services can help to break the barriers that prevent them from reaching their goals. Tobacco cessation would be one of the fields that public health, social services, and medical intervention complement each other to achieve the highest success possible. As the nation called to address the root courses of health disparities, the leaders in the Oswego community realized that existing medical care, public health, and social service systems were parallelly serving the community to reach these system's disparate goals. The high smoking rates of the county intertwined with other issues, such as lack of knowledge about the health risks of smoking, poverty, and shortage of transportation. So, the leaders decided to bring public health, medical care, and social services together to address the high prevalence of tobacco use in the county. As for choosing what population to target, it took a series of extended discussions. Eventually, it was decided to focus on pregnant women for the following reasons: As a rural community that is short of resources, a feasible approach is to work on a small, focused smoking population; Although less female smokers than males in the county, working on the women would impact more people. To change a man is only changing one person; to change a woman we can change a household, many people, and generations,” one leader said; The health burdens from tobacco are disproportionally tilted toward the disadvantaged populations, among pregnant women as well; and Pregnancy is an ideal window” for tobacco cessation. (S Schneider et al.: Smoking cessation during pregnancy: a systematic literature review, Drug and Alcohol Review Vol 29, 2010). The target population is every pregnant woman who seeks prenatal care at the Oswego County OB/GYN annually. Approximately, 1200 births occur in the county every year, and the clinic provides services to half of them, 600 annually. The remaining pregnant women get their obstetric care in neighboring counties. By screening every woman getting prenatal care at Oswego County OB/GYN, the program reaches100% of the target population. And with educational information on health risks of first- and second-hand smoke to every pregnant woman, who then shares the information with their households, neighborhoods, and workplaces, the program makes impacts on the community as Oswego is a well-netted community. If every pregnant woman shares what she has learned about tobacco with five of her relatives, neighbors, or co-workers in the county, the message will reach 3,000 residents of the county, or 2.5% of the total population, each year. By addressing pregnant smokers' health concerns, the program not only reduces smoking during pregnancy and after delivery but also empowers these women to make healthy choices. As this program goes on, the partner agencies' other activities and programs, such as education and outreach, smoke-free rental property promotion, and law/regulation, offer opportunities for women to make choices for their families and their loved ones to live a healthier life. By working together, the leaders believed, agencies should better address smoking among pregnant women than each agency works separately and be able to make impacts on the health norm regarding tobacco in the community. Prior to the partnership formation, many agencies had been tackling smoking issues in the county. A state-funded regional tobacco cessation center located in a neighboring county serves Oswego County as one of the fourteen counties the center covers. The county health department and the only hospital in the county house certified tobacco cessation counselors to serve, although they were rarely called for several years. Some social service agencies worked on tobacco control and other tasks (such as maternal and child health) with small funding from the state and donations. Other agencies carried broad tasks for community health and wellbeing. Clinicians encountered many smokers, but their knowledge and skills in tobacco cessation had not been updated for years. These agencies worked hard but separately on the same goal of reducing tobacco use in the community. Little success was brought about for years. The current practice is successful in reducing tobacco rates in the community by bringing the scattered resources together and synergizing existing forces in a partnership program. The partners have a shared vision, and each partner has its committed responsibilities and equal decision-making power. The applicant practice is innovative in two aspects: 1) locally link public health, social services, higher education, and medical care together to address a community health concern; and 2) creatively use/modify proven successful strategies. In 2003, the World Health Organization (WHO) directed future primary care to place emphasis on community participation and intersectoral collaboration … when so many health issues … cannot be effectively addressed by health systems working in isolation.” The WHO also suggested some ideas, such as use leaders to promote intersectoral collaboration,” build the mechanisms for collaboration at every level, from national to local,” and integrate health into definitions and processes of wide community development.” (World Health Organization: Primary health care: a framework for future strategic directions, 2003). The United States hears similar, more specific, voices. The Institute of Medicine calls for public health and medical care moving along a path of integration” for the shared goal of promoting the better health and well-being of all Americans (Institute of Medicine: Primary care and public health, exploring integration to improve population health, 2012). American Academy of Family Physicians (AAFP) supports the Institute of Medicine's direction and states individual health is inseparable from the health of the larger community which, working up the ladder, ultimately determines the overall health of the nation. To better align these individual and community forces, primary care and public health needs to reconnect.” (AAFP Position Paper: Integration of primary care and public health, 2014). Recently, Robert Wood Johnson Foundation and Woodrow Wilson School of Public and International Affairs, Princeton University report six strategies to integrate social services and medical care at the state level with sample practices from many states; furthermore, the report concludes that meaningful linkages and integration between health care and social service providers can effectively address health-related social service needs and improve overall population health (Robert Wood Johnson Foundation and Woodrow Wilson School of Public and International Affairs, Princeton University: Integrating health care and social services: moving from concept to practice, 2016). Calls for integrated community collaboration have been voiced for more than a decade, and many successful practices in integrating medical care and public health at the local level, and integrating medical care and social services at the state level have been reported in recent years. But very few examples have emerged that integrate medical care, public health, and social service systems together at the local level. The complexity of integration of these three systems is because they provide a wide range of services that are funded separately and governed by different policies in different agencies in the same community. A key innovation of this program is that the program links public health, social services, and higher education to medical care at the local level, while it respects all existing policies and rules that govern each partner. The partnership has made inexpensive and seemingly simple steps to bring the existing, limited resources together. These steps generate significant impacts on smoking pregnant women and produce measurable improvements in smoking rates and in changing the health norm regarding tobacco in the community. The second innovation of this program is that the program partners are all the experts in their field and able to bring proven successful strategies together to address unique local challenges; when adopted strategies do not work with Oswego situations, partners are able to modify and develop new strategies. One of the examples is to replace the texting and social media support with the peer support. It is known that tailored texting messages are a proven effective tool in tobacco cessation (Whittaker R, et al.: A multimedia mobile phone-based youth smoking cessation intervention: findings from content development and piloting studies, Journal of Medical Internet Research Vol 10, 2008). But women in this rural area have limited data plans to access text messages and social media. Then the program quickly adopted the peer education model successful in promoting breastfeeding and modified the breastfeeding peer support model for tobacco cessation. It was a successful move.
Tobacco
The partnership was an outcome of the county health department's outreach presenting the County Health Rankings by Robert Wood Johnson Foundation and the University of Wisconsin. In late 2012 and 2013, Oswego County Health Department carried out an extensive campaign to disseminate the ranking data. The revealing data brought concerned community members together who started to look at how to improve community health in Oswego County intensively. In early 2014, some local agency leaders decided to tackle on the high prevalence of tobacco use in the county. These agencies included Oswego County Health Department (OCHD); Oswego County OB/GYN, P.C., a private, for profit medical practice and the only obstetric clinic in the county; Integrated Community Planning, Inc. (ICP), a local non-profit public health and social service agency with public health and social services in tobacco control and early childhood development; Oswego County Opportunities, Inc.(OCO), a non-profit community action organization, providing a broad range of public health, social and medical services; State University of New York at Oswego (SUNY Oswego); the Central New York Regional Center for Tobacco Health Systems at St. Joseph's Hospital Health Center (the CNY Regional Cessation Center), a state grant funded program that reaches out to healthcare provider organizations and delivers evidence-based tobacco dependence treatment in the central New York region's 14 counties including Oswego, and Oswego Hospital, the only community hospital in the county. The agency leaders were determined to address the social acceptance of tobacco as they tried to reduce tobacco use in the community. When they started planning, they shared the knowledge about the resources for tobacco control and the limits of using these resources imposed by agency or funder's policies. It was followed by a long process of looking for existing models and practices and reviewing published literature. Bringing all information together, they started discussions as to the target population. The leaders decided to target the pregnant women, as they realized that to change a man is only changing one person; to change a woman we can change a household, many people, and generations,” and to bring about community's cultural changes of tobacco norm. To reflect the intention of impact for the whole community and to call for other smokers to join tobacco cessation, the group named the partnership program Smoke Free for My Baby & Me.” The program is free and voluntary for expecting mothers. The lime green color was chosen as the color of the program. A logo for the program was also designed. The leaders set the goal: To change the community norm regarding tobacco by addressing pregnant women's social and financial needs to quit smoking successfully and by empowering them to make healthy choices. To achieve this ambitious goal, the leaders decided to implement an unprecedented program to support pregnant women to quit smoking and remain smoke free after delivery. According to the literature review, many studies and programs showed that the clinical intervention cessation rates improved after adding health education, material incentives, and social supports. But no study combined public health, social services, and clinical interventions to address community tobacco norm via working on a certain population of smokers. A review article of tobacco cessation during pregnancy and after delivery revealed that the cessation rates were 16% with intervention while 9% without intervention during pregnancy and only 20% of women remained smoke free a year after delivery (A Einarson, et al.: Smoking in pregnancy and lactation: a review of risks and cessation strategies, European Journal of Clinical Pharmacology Vol 63, 2009). The leaders are determined to align local resources, including public health, higher education, material incentives, social supports, and medical continue education to support the clinical intervention of tobacco cessation for pregnant smokers. They set four objectives of the programs: Educate all obstetric patients about health risks of first- and second-hand smoke; To enroll 30% of smoking pregnant women in the clinic into the program at any point of time, and serve more patients with the public insurance than those with the private insurance; To retain 30% of enrollees who stopped smoking during their pregnancy; and To strive for 30% of the quit women during pregnancy to remain smoke-free through the baby's first birthday. Oswego OB/GYN was selected as the center of the partnership, an ideal site to educate all pregnant women about the first- and second-hand smoke and the health risks of tobacco use, and to enroll women to participate in the clinical cessation intervention. Other agencies were committed to providing assistance to make sure that the needs of the clinical practice and the enrolled women were met. In the planning stage, an assessment found three gaps should be filled before the program could be rolled out. The gaps were: 1) funding to purchase some devices for monitoring carbon monoxide and verifying smoking reduction, and to purchase diapers as an incentive; 2) a screening tool to enroll only ready participants in order to use limited resources efficiently; and 3) a training for clinicians to update their skills and knowledge on evidence-based clinical interventions and to make them familiar with available resources to support the clinical intervention. The partners also decided to have regular meetings to timely assess the program and evaluate the progress and outcomes of the program. Any decision of change would be made at the meetings, and every partner would have the same weight in decision-making. The following highlights the partnership program's implementation process in a snapshot. 1. The start-up funding Grants from a health foundation and insurance companies comprised the majority of the start-up funds, which was spent in purchasing carbon monoxide meters, diapers, and other promotional items. 2. The development of the screening tool A survey questionnaire was developed by the Department of Communication Studies, SUNY Oswego as a screening tool. The purpose of the screening is to assess the readiness to quit smoking among pregnant women and to prioritize the ready ones in order to use limited resources efficiently. The survey includes variables: demographics; current smoking status and smoking history; household smoking environment; smoking attitude, perceived norms on smoking, and self-efficiency and intention on quitting smoking. Based on the Stages of Change (SOC) Model, also known as the Transtheoretical Model (Prochaska JO, et al.: Predicting changes in smoking status for self-changers, Addictive Behaviors Vol 10, 1985), the behavioral change to quit smoking is a continuum of five stages: Stage 1: Precontemplation stage – not considering quitting Stage 2: Contemplation stage – planning to quit in the next six months Stage 3: Preparation stage – willing to set a stop date in next month Stage 4: Action stage – stop smoking Stage 5: Maintenance stage – prevent relapse Following the SOC model, clinicians at Oswego OB/GYN are able to focus their time and efforts on those patients in stages 5, 4, and 3, and check up with those in the stages of 2 and 1 periodically. Before the program was rolled out, the Institutional Review Board at SUNY Oswego also reviewed and approved the protocol as a research project involving human subjects. 3. The training for clinicians The CNY Regional Cessation Center held a one-day training for clinicians, public health educators, and other involved personnel. The training included health risks and addiction associated with smoking, secondhand smoke, smokeless tobacco products, the New York State tobacco control and achievements, the role of healthcare providers in tobacco cessation and the major steps to intervention (5 A's: ask, advise, assess, assistant, and arrange), how to address patients with their challenges in quitting, such as craving, stress, weight gain, etc., the technique to motivate resistance of patients (5 R's: relevance, risks, rewards, roadblocks, and repetition), cessation medication, cessation during pregnancy and lactation, and strategies and techniques to support patients in quitting. The training also included a START” program that helped patients to develop a quit plan. The START” stands for: Set a quit date; Tell family, friends, and co-workers the plan to quit smoking; Anticipate and plan for the challenges in quitting; Remove cigarettes from home, car, and workplace; Talk to the doctor about quitting. Local agencies shared information about their resources for reducing tobacco use with clinicians at the end of the training. The training laid a broad foundation for clinicians to interact and engage patients in reducing tobacco use. The clinicians not only updated their knowledge and skills in clinical intervention but also became knowledgeable on connecting local community resources to the patients' tobacco quitting needs. 4. The clinical intervention At the Oswego County OB/GYN, clinicians are trained to apply a non-judgmental manner to address tobacco issues with their patients. One technique that they use is face-to-face peer-like conversations on tobacco issues with patients. Each pregnant woman gets a short screen when she first seeks prenatal care for her current pregnancy at the clinic. The screen asks about patient's smoking history, her current smoking status (including the secondhand smoke), and offers her a smoke-free multiple-unit housing list if she rents. In this screening process, each pregnant woman is educated about the health risks of smoking and secondhand smoke to the mother and baby. Women are encouraged to talk with their spouses, partners, and other family members about benefits of quitting. This screen takes one to several minutes depending on the patient's answers. For those pregnant smokers, the second screen applies. This screen uses the survey developed by SUNY Oswego faculty and is administered by a trained nurse. The screening takes 10-12 minutes to finish. The screening will place each woman in one of the five stages: Stage 1: Precontemplation stage – not considering quitting Stage 2: Contemplation stage – planning to quit in the next six months Stage 3: Preparation stage – willing to set a stop date in next month Stage 4: Action stage – stop smoking Stage 5: Maintenance stage – prevent relapse After screening, clinicians advise all patients in different stages to take actions to quit. And the Smoke Free for My Baby & Me” program is introduced to women in stages 5, 4, and 3. It usually takes 30 minutes or more to introduce the program. The introduction includes detailed information on tobacco and its health risks, how the program measures and monitors her quit process, what services the program offers to help her to quit, what challenges she might face, what rewards she can expect, what are the benefits to quit smoking with the program, and what questions she has about her and her baby and about the program. If a patient wants the program, she is asked to sign an agreement and officially be enrolled in the program. She will also be assured that the program is free and she can leave the program at any time without any obligations. Then she receives a lime green bag with the logo of the program, containing a stress ball, a bottle of hand sanitizer, a pen, some nail-filers, hard candies, gum, and tobacco-related pamphlets. After signing in, a trained nurse will show participants how to use the carbon monoxide meter and teach how to interpret the readings. Each patient gets her first carbon monoxide level recorded at this time. For those who have stopped smoking after they learned of their pregnancy, the nurse will compliment and encourage them to stay away from tobacco. For those who are ready to quit but still smoking, the nurse will apply the START program and other approaches. The nurse coaches them to scale down tobacco use gradually, encourages them to tell of their decision of quit smoking to their relatives and friends, instructs them to speak out about their challenges, and arranges community resources to support these individual's needs. For those who have not consider quitting, the nurse will check with them periodically to see if they are ready to quit. After enrollment, the participants will be scheduled for clinical counseling sessions with trained nurses, usually once a month (If needed, additional sessions are provided) and primarily before or after routine prenatal care and postpartum appointments. Due to the many successful participants' involvement in the program, Oswego County OB/GYN continues to provide clinical counseling for those women who are working toward the end landmark – postpartum tobacco free for one year, after standard postpartum care would have ended. In the clinical counseling sessions, the trained nurses will test and record participants' carbon monoxide level, then review and interpret carbon monoxide data with the participant. Nurses focus on helping program enrollees overcome barriers to success. The common barriers are negative mood, life changes (including living with a newborn), being around other smokers, craving, and other stressors. During these sessions, the nurses apply the 5 A's intervention steps and the 5 R's motivation technique to engage participants to remain tobacco free. In these sessions, the nurses also hand out gas cards or bus passes to those who need, deliver diapers as incentives, re-introduce the peer supporter if patients desire quick responses and more frequent conversations, and connect other community resources to meet the individual's different needs. One nurse at the clinic said, The women themselves lead this program … (I give them) what supports will work best for them.” These counseling sessions usually take 30-45 minutes. Nurses will also follow up with those who are not ready to quit, timely assist them to set up quitting dates when they are determined, and enroll them when they are ready. 5. The community supports An Institute of Medicine (IOM) presentation in 2012 called for a concerted effort align under a common goal” to integrate public and private sectors, and primary care and public health integration to achieve substantial and sustained population health (http://www.nationalacademies.org/hmd/~/media/Files/Activity%20Files/PublicHealth/PrimCarePublicHealth/PCPH-Report-Release-Presentation-03-28-12.pdf, accessed on December 2, 2017). In the Smoke Free for My Baby & Me” program, partners have come together under a common goal, and community resources merge to support the clinical intervention. There are some reports of successful integration at the state level (see in the same report of the IOM), but it has not seen a successful and sustained intersectoral integration of different agencies and resources to support a clinical intervention at the local level reported. Community resources to support clinical tobacco intervention in the Smoke Free for My Baby & Me” program include providing diapers for an incentive, facilitating transportation, the texting and social media support (later changed to the peer support), policy advocacy, and program coordination. A. Diapers and other incentives Many studies indicated incentives improve the success of tobacco cessation programs (Golpp KG, et al: A Randomized Controlled Trial of Financial Incentives for Smoking Cessation, Cancer Epidemiology, Biomarkers, and Prevention Vol 15, 2006; and Heil SH, et al: Effects of voucher-based incentives on abstinence from cigarette smoking and fetal growth among pregnant women, Addiction Vol 103, 2008).Having realized that the social, economic status influences individual's health behaviors, the Smoke Free for My Baby & Me” program embeds a small incentive to engage more pregnant smokers in socioeconomically disadvantaged populations. Program participants who quit smoking during pregnancy and continue to remain tobacco free, verified by the carbon monoxide meters, are eligible to receive $25 worth of diapers each month after the baby is born for 12 months. Integrated Community Planning has provided the supplies for green goodie bags to welcome pregnant women when signing on to the program. Women who successfully reached the landmark of 12 months' tobacco free after delivery, also received a blanket for their babies. B. Facilitating transportation needs Geographic barriers to access healthcare services is a well-known challenge for rural residents reaching healthcare facilities (Arcury TA, et al.: Access to transportation and health care utilization in a rural region, Journal of rural health Vol 21, 2005). Poverty exacerbates the challenge. Roads reach out to almost every resident in Oswego County and a public transportation system reaches most populous towns and villages. But still many people in the county do not have a car or can not afford bus passes. To help participants overcome the barriers, the Integrated Community Planning provides gas cards and bus passes to Oswego County OB/GYN. It is at the clinicians' discretion to hand out the gas cards and the bus passes at no cost to the program participants. The facilitation of transportation ensures continuous engagement of participants in a timely manner. According to some clinicians, this service also helps some patients to keep with their routine prenatal appointments. C. The texting and social media support to the peer support The texting and social media are relatively new but have been successfully used in tobacco cessation intervention (Cobb, NK, et al.: Online Social Networks and Smoking Cessation: A Scientific Research Agenda, Journal of Medical Internet Research Vol 13, 2011). The Department of Communication Studies of SUNY Oswego developed a Facebook page and was ready to send pregnancy tobacco cessation-related texting messages out. But due to participant's concerns about the limited data plans they had monthly, very few signed up for this service. Oswego County Opportunities (OCO) had a successful experience in promoting breastfeeding through peer counseling and support for expectant and breastfeeding mothers. The counselors provide a wide range of support, assistance, and education on topics such as identifying good milk supply, nutrition facts, positioning and returning to work. The counselors are experienced breastfeeding moms. To fill the gap left by removing the texting and social media supports, OCO suggested transplanting” the peer counseling model for breastfeeding to tobacco cessation. The partners agreed, and OCO hired a part-time peer supporter, who was a breastfeeding peer counselor and a successful Smoke Free for My Baby and Me” graduate. She was trained with additional information on and skills for tobacco cessation intervention and began supporting other participants. In the program enrollment process at the clinic, new participants are given the peer supporter's contact information and encouraged to contact her when they feel help is needed. Without a fixed working hour, the peer supporter is almost accessible 24/7. The peer supporter sends encouraging texts to enrollees who want this and checks in with phone calls to see how they are doing. She offers suggestions and passes along what she is learned. Handling life changes, negative mood, craving, being around other smokers, and stress are the common topics in peer support's interactions with the enrollees. One technique she often offers is the 5 D's in dealing with a craving: Delay (to pick up a cigarette), Drinking (water), Do something else, Deep breathing, and Discuss (thoughts and feeling with your supports). A self-help instructional book titled Allen Carr's easy way to stop smoking is also circulated among program participants. The book was recommended by the peer supporter. OCO purchased several copies for the circulation. In the past two years, since the Smoke Free for My Baby & Me” was rolled out, about 8% of program participants sought peer support for their cessation efforts. These women were usually struggling ones. Many of them came in the program and dropped, and came back again. Some of them picked up tobacco in the period of peer counseling and later tried to quit again. A few even signed in but never answered the peer counselor's call or texting and eventually dropped out. The frequencies of interaction with the supporter varied between four to 18 times in this duration. One-third of women who sought peer support were successful in keeping tobacco free for 12 months after the babies were born. D. Policy advocacy Integrated Community Planning (ICP) has been working on decreasing secondhand smoke exposure in multi-unit housing, with emphasis on policies that protect the health of low-income residents in Oswego county and in the region. The smoke-free rental properties are proven effective in reducing tobacco use and secondhand smoke exposures (Pizacani BA, et al.: Implementation of a Smoke-free Policy in Subsidized Multiunit Housing: Effects on Smoking Cessation and Secondhand Smoke Exposure, Nicotine and Tobacco Research Vol 14, 2011). The direct benefits of this policy are: improving indoor air quality, enhancing resident's health, reducing fire risks, and reducing maintenance costs. ICP has assisted the Housing Authority of the City of Fulton to adopt a non-smoking policy for all residents in public housing units and set up steps to enforce the policy. Promoting this policy indirectly promotes the awareness of health risks of tobacco for this program. ICP continues to provide an updated a list of smoke-free rental properties in the county to the Oswego County OB/GYN ICP also takes opportunities to reach out to the county legislature, especially the legislative Health Committee, to promote tobacco-free outdoor policies. Tobacco-free outdoors will greatly reduce the secondhand smoke exposure for people, especially children. With ICP and its staff's diligent outreach efforts, the county Legislature passed a local law to ban tobacco and e-cigarettes on all campuses owned or rented by the County in 2016. E. The roles of the local health department in the partnership In a report by a non-profit organization in 2014, funded by the Robert Wood Johnson Foundation, states, by 2020, state and local health departments will be more likely to design policies than provide direct services; will be more likely to convene coalitions than work alone; and be more likely to access and have real-time data than await the next annual survey. These new required skills and abilities characterize a new role for health departments as the chief health strategist” for a community”(http://www.resolv.org/site-healthleadershipforum/files/2014/05/The-High-Achieving-Governmental-Health-Department-as-the-Chief-Health-Strategist-by-2020-Final1.pdf, accessed on 12/03/2017). Oswego County Health Department (OCHD) is experiencing these changes. Over the past several years, the department phased out some direct service programs and sustained continuous budget cuts. Due to staff and funding shortages, it is impossible for the department alone to roll out any new programs. But working in the Smoke Free for My Baby & Me” partnership, the department is changing towards the report's direction – as a local health strategist: 1. The department serves as an information center by collecting, reviewing, analyzing, and disseminating health data. Based on data the department set health priorities for the community. By data sharing, the department gains community members' attention on health issues and explores new opportunities for collaboration to improve community health. 2. The department serves as an advocacy center for public health. The department advocates for the adoption of local laws and rules that address health issues to the legislative body, advocating for funds to projects and programs that improve health to the upper administration, and fostering collaboration and partnerships that break barriers in promoting health to all community members, especially key stakeholders. 3. The department serves as a coordination center for local health. The department motivates interested parties to keep working together, monitors the progress of projects and programs, and reports achievements within the partnership/collaboration and to the community. Specifically, in the Smoke Free for My Baby & Me” partnership, OCHD initiated stakeholders and partners' attention to tobacco use in the community; OCHD fostered the partnership among agencies; OCHD reviewed and disseminated existing practices for the partnership's choosing a target population and planning actions. OCHD continues to monitor the progress of the program by facilitating monthly meetings, identifying resources, collecting program data, and drafting press releases to promote the program to the community, supporting partners' institution activities and goals (such as promoting tobacco free outdoors), connecting all partners to keep them informed, and aligning resources to achieve the program's objectives. F. The timeframe and the further program goals When the partners started the Smoke Free for My Baby & Me” program, they did not perceive a time to stop the program as they realized that it would take many years to reduce tobacco use in the community and generations to improve the county's health status. Recently the program is expanding in the county. Oswego County Opportunities (OCO) has implemented the Smoke Free for My Baby & Me” program to the agency's maternal and child health care sites to include expecting mothers who do not go to Oswego County OB/GYN for the prenatal care. This expansion also includes mothers with young children (less than two-year-old) and encourages and incentivizes them to quit smoking. The agency's maternal and child health care program provides home visiting services. Now OCO staff brings the Smoke Free for My Baby & Me” to client's homes. These expansion measures make the program available to more female smokers to quit in the county than before. These expansion measures make the program accessible to more women who live in remote areas and face transportation challenges. For a rural community, any help in overcoming transportation barriers is significant. In the meantime, the Smoke Free for My Baby & Me” is getting other county health agencies interest as the CNY Regional Cessation Center promotes the program in its service region of the other thirteen counties. The partners are determined to enhance the program in the county and provide experience and success to other local health agencies out of the county. It is planned that a study of what social and environmental factors facilitate pregnant and postpartum women to quit smoke and relapse will be conducted as more cases are accumulated. As more resources become available, it will be interesting to make a comparison of birth outcomes between newborns in the program and not in the program. G. The start-up costs, in-kind contributions, and the annual cost Smoke Free for My Baby & Me” Costs Start Up Costs Total Start Up costs - $36,500.00 Training Diapers Brochures Posters Incentives Peer Educator CO2 Monitors Mouthpieces Data Analysis Initial Set up In-Kind Staff meeting time Monthly 1 hour meetings Staff training time One 8-hour training per year Computer Practice data tracking Copies Approximately 50 per participant Phone/Text Contact with clients Screening Tool SUNY Oswego Data Analysis SUNY Oswego On-going Funding Services/Needs For 30 participants, the cost is $12,000 per year Diapers $25.00 per month per participant Bags 1 per participant Candy/Gum As needed for stress reduction Stress balls 1 per participant Blankets 1-year after delivery follow-up incentive Mouthpieces 1,000 per year ($150) Gas cards and Bus passes As needed Peer Educator Stipend
The Smoke Free for My Baby & Me” has been rolled out for two years and is an ongoing program in Oswego County. When it started, the partners set the objectives: Educate all obstetric patients about health risks of first- and second-hand smoke; Enroll 30% of smoking pregnant women in the clinic into the program at any point in time, and serve more patients with the public insurance than those with the private insurance; Retain 30% of enrollees who stopped smoking during their pregnancy; and Strive for 30% of the quit women during pregnancy remain smoke-free through the baby's first birthday. Oswego County OB/GYN is not only the center for educating, reaching out and serving the women for reducing tobacco use but also is the major site to collect data for monitoring the progress of the Smoke Free for My Baby & Me.” The clinic collects the following data and brings to the partnership meeting every month: Number of pregnant women it serves currently, Number of smokers among these women, Number of smoking women who are enrolled in the program, Number of patients in the public and private (including self-pay) insurances in the above three groups of women, Number of women who are receiving diapers, Number of enrollees who signed up for digital and social media services (late for peer support services); and the following accumulated numbers of: women who dropped out of the program (for any reason) women who dropped out of the program after receiving one or two sets of diapers women who dropped out of the program after receiving three or more but less than six sets of diapers women who dropped out of the program after receiving six or more but less than nine sets of diapers women who dropped out of the program after receiving nine or more but less than twelve sets of diapers women who have received twelve sets of diapers successful in the program. In the beginning, these numbers were keyed into a calculator to generate percentages that the program wanted to measure the progress of achieving the objectives. Recently, an Excel spreadsheet was developed, and the numbers have been keyed in, and the Excel calculates the percentages. Monthly data review at the partners' meeting has continuously shown that since the program started in the summer of 2015 the program has: reached 100% obstetric patients about health risks of first- and second-hand smoke; enrolled 30% of smoking pregnant women in the clinic in the program; retained 75% or above of program participants tobacco free through their pregnancy; achieved 47% of the quit women during pregnancy to remain smoke-free through the first year after baby's first birthday; and in a comprehensive assessment around the two-year anniversary of the program data show: in Oswego County OB/GYN, the obstetric patients with the public insurance and with the private (including self-pay) were 52% vs. 42%; however, percentages of the program participants were 79% vs. 21%. The percentages above indicate that the partnership program has achieved its objectives set up at the beginning of the program. Further analysis revealed the Smoke Free for My Baby & Me” program achieved better outcomes than most reported studies but still show the same trend of high postpartum relapse around six months after the delivery. According to a review, the quit rates of even the most effective ‘best practice' interventions for pregnant smokers seldom reach or exceed 20% … Over two thirds of women who do quit smoking during pregnancy return to cigarettes within six months following delivery” (Orleans CT, et al.: Helping pregnant smokers quit: meeting the challenge in the next decade, Tobacco Control Vol 9, 2000). The Smoke Free for My Baby & Me” partnership achieved 78% participants smoke free during pregnancy; among them, the postpartum relapse rates were 48% before babies reach three-month-old, 52% before six-month-old of the baby, and all women who were smoke free when their babies reach six-month-old all remained so at their babies' first birthday. It is an almost four times higher quit rate and lower relapse rate than those reported, but the relapse pattern seems similar, around the six months after the babies were born. In addition to the program's own internal measures, some third parties' registry or survey data displayed some community impacts of the Smoking Free for My Baby & Me.” The Statewide Perinatal Data System is a registry that collects data on maternal and neonatal services. One module includes the smoke rate by the third trimester. The percentage of women with the public insurance who are still smoking by the third trimester in Oswego County has drastically reduced since the program started and in 2016 this percentage in Oswego County was the first time below the average of neighboring counties. Here are the details: Oswego Average of Neighboring Counties 2012 84.97% 80.77% 2013 84.14% 78.50% 2014 87.77% 77.96% 2015 81.89% 81.21% 2016 79.15% 81.12% A regional survey shows that the partners in the trend to approach their ambitious goal of changing the community's health norm regarding tobacco via working on the pregnant women in the community. The community tobacco survey is usually conducted approximately every two years among adult county residents via landline and cellular phones. The purpose of this survey is to collect tobacco-related information for planning and advocating future anti-tobacco activities in the county. In Oswego County, it is funded by one of the partners, ICP, and run by the Joel LeLone Consulting in Watertown, NY. Many other counties in the State of New York have the same or very similar surveys. According to the community tobacco survey, the awareness of the tobacco's health risks has drastically increased among adult residents in Oswego County, compared with the adults in the region, since the Smoke Free for My Baby & Me” program was implemented in 2015. Oswego Regional Average 2008 22.8% 28.4% 2010 19.3% 31.9% 2014 25.8% 39.8% 2016 41.0% 36.0% Note: no survey was conducted in 2012. These data indicate that Smoke Free for My Baby & Me” program has made its impacts on Oswego adults and people in Oswego County are more aware of the health risks of tobacco than people in other counties in the region where there are no similar programs like Smoke Free for My Baby & Me.” The change of the health norm regarding tobacco is happening in the community. The Smoke Free for My Baby & Me” partners meet monthly to review data and discuss the progress of the program. Timely meetings make it possible to identify problems and find solutions quickly. One example was the adoption and modification of the peer support program to the partnership intervention. More details of the adoption and modification were described in the previous narratives. When they were asked to evaluate the program by their own experience, one participant said, This program really gave me the support and extra motivation I needed to quit smoking and remain smoke-free.” Another participant added, We love the diaper incentive … We have saved a ton of money and become smoke-free.” A clinician observed, One result of this program is its ability to affect change in families and groups. Those at home are influenced by a women's choice to quit smoking, whether it's a show of support, like going outside to smoke, or it's making their own decision to quit. The women bring home all the information, tools and supports that they're learning from their experience and that benefits the whole family.” Some participants even brought their significant others to the clinic to quit smoking together.
The Smoke Free for My Baby & Me” was an outcome of the county health department's outreach with the local health status by the County Health Rankings. The revealing data urged the community leaders to take actions. The leaders developed an innovative intersectoral partnership of a clinic-centered with support from public health and social services to reduce tobacco use among pregnant smokers. The objectives of this partnership program are to assist female pregnant smokers, especially those socioeconomically disadvantaged, to quit smoking during pregnancy and to prolong these women's postpartum tobacco free status. The goal of the program is, by working with women and through women's familial and social connections, to influence community norm regarding tobacco. Over the past two years since the program was launched, data collected at the clinical intervention site indicate that the program achieves its objectives. The smoking cessation rate increase during pregnancy and the postpartum relapse rate reduction are much better than most published studies reported. More disadvantaged pregnant women benefit from the program. A state survey shows that the rate of pregnant women in their third trimester smoking rate has drastically reduced in Oswego County since the program was launched. Another survey reveals that the program is approaching its goal of changing community norm regarding tobacco. It shows that county adult residents' knowledge about the health risks of tobacco has drastically increased since the program was launched. The successes of the partnership were publicized in local newspapers several times in the past years. The outcomes of the program were presented at the state public health association's annual conference, the regional tobacco control summit, and the NACCHO 2017 annual conference. The successes of the program have gained local institutes attention and support. In addition to some community charities' occasional donations, the Greater Oswego United Way granted a two-year grant for sustaining and expanding the program in the County. The county Legislature allocated matching funds for this program in its 2017 and 2018 budgets. Encouraged by the successes of the program and increased local support to the program, the partners are committed to continue and to grow the program. The program is expanding to OCO's maternal and child health service sites to serve more women and to reach women in remote areas of the county. It is in the plan that as more women participated and the cases accumulated SUNY Oswego will conduct a research project to explore: What are the barriers that prevent pregnant and postpartum women to quit smoking; To what extent, the incentives and other social services facilitate women's tobacco cessation during pregnancy and after delivery; and What are the major causes of postpartum relapse and how to prevent them? Another study is in the scope. It is a health benefit analysis by comparing birth outcomes between mothers who are enrolled in the program and who are not. This study will need more cases and extra resources. Lessons learned in relation to practice are: The National County Health Rankings carry much weight in getting local attention of health issues, especially the key stakeholders', and in bringing relevant agencies together to look at and work on the issues; The innovative approach to an intersectoral partnership including public health, social services, higher education, and clinical care can effectively overcome cessation barriers for pregnant and postpartum women, especially for those disadvantaged; The contemporary occurrence of the implementation of this tobacco cessation program and the increment of adult's knowledge about the tobacco's damages support the idea that it is an effective way to change the community norm regarding tobacco by reducing female smokers and empowering women for healthy choices; A program that was successful in one setting may not succeed in other conditions, such as the failure of applying the texting and social media support for tobacco cessation among pregnant smokers in Oswego County. Lessons learned in relation to partner collaboration are: The formation of shared goals and objectives in early stage of a partnership helps the partnership to become strong and stable; Regular meetings, continuous monitoring the progress, and collective decision-making help the program make necessary changes effective; and Sharing knowledge and resources helps the partnership quickly and effectively respond to expected and non-expected incidents as the program advances.
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