babyClear
The North East`s regional approach to
reducing maternal smoking rates
Martyn Willmore - Fresh Smoke Free North East
Hilary Wareing - Tobacco Control Collaborating Centre
Acknowledgements
This work has been a real collaboration between a number
of people/organisations. In particular, we would highlight:
- North East Strategic Health Authority
- Institute of Health and Society, Newcastle University and
Teesside University
- North East Clinical Innovations Team for Maternity &
Newborn
- Colleagues from Great Yarmouth and Waveney
- Jane Beenstock, Speciality Registrar in Public Health has
been instrumental to this project
http://www.implementationscience.com/content/7/1/36
Why we have a focus on this
England
25.0%
23.5%
22.2%
22.7%
North East
22.2%
21.1%
20.7%
14.0%
13.5%
13.2%
12.7%
2009/10
2010/11
2011/12
2012/13
SATOD rates %
20.0%
19.7%
15.0%
15.1%
14.4%
14.4%
10.0%
5.0%
0.0%
2006/07
2007/08
2008/09
Picking up where I left off….
• In 2011, Fresh presented on some
research that had been conducted
with NE midwives
http://www.uknscc.org/uknscc2011
_presentation_72.php
• This research attempted to tease out the barriers perceived
by midwives when discussing stopping smoking
• Questionnaire completed by over 500 NE midwives, based
on Theoretical Domain Framework…..
Key findings from research…
- Four main issues identified following
questionnaire and development of local action plans:
- Skills and training. How to make training consistent
across North East? Specific issues around CO monitors
- Resources. Prompts/triggers to help midwives raise issue
in a more structured way. Access to CO monitors
- Carrying the message consistently. Common script for
all midwives with key messages. A change in language
used (i.e. “low birth weight”)
- Managing relationships. Mechanisms for overcoming
potential negative reactions to discussing smoking
babyClear systematic approach
We identified a system called “babyClear”, which would
address many of these issues:
•An approach to carbon monoxide testing for all pregnant
women and an opt out referral system
•Promotional materials and written information developed
using an insight driven approach
•Localised protocols, care pathways and
monitoring systems
•Skills training to support advisors to
work effectively with pregnant women
babyClear systematic approach
• An opportunity for specialist advisers to explore new
ways to reach out to those women not engaged with
the service - including implementation of a risk
perception tool with women who decline support at
booking
• Administrative / call centre staff training to increase the
proportion of women accepting appointments
• A robust performance management
system
Pre-Implementation
•Regional funds made available by SHA.
•Following procurement exercise, the Tobacco Control
Collaborating Centre secured contract to deliver babyClear
•Newcastle University evaluating project`s quantitative
outcomes, and Teesside University the qualitative outcomes
•A randomised order of project roll-out was conducted:
– Cluster 1 – Durham & Darlington (Dec 2012-Jan 2013)
– Cluster 2 – South of Tyne and Wear (Feb-March 2013)
– Cluster 3 – North of Tyne (April-May 2013)
– Cluster 4 – Teesside (June-July 2013)
Implementation
•Training is now taking place within Cluster 4. Feedback so far
has been very positive.
•Over 220 midwives so far attended 2-hour standard training
•All midwives attending have received babyClear packs and
associated resources (e.g. CO monitors)
•Over 94 stop smoking advisors have attended one or two day
programmes
•23 call centre / admin staff have attended a training
programme
•Main issues have involved resource and logistics to deliver
the “risk perception” intervention
Quotes
What was the most valuable to you?
(Stop Smoking Advisors)
• “Having the time to practice asking open questions”
• “Learning to deal with heart-sink statements”
• “New ideas to try to engage women at the assessment
appointment”
• “Not assuming that because they have attended they are
ready to quit”
• “The difference in working with pregnant smokers”
• “Learning different techniques to engage pregnant
women”
Quotes:
What was the most valuable to you?
(Stop Smoking Administrative Staff)
• “How to engage with women in an effective way”
• “The importance of being the first point of contact”
• “Understanding the whole process and importance
of our role”
Quotes:
What was the most valuable to you?
(Midwives)
• “Much more realistic time for a brief intervention”
• “Realising the harm smoking causes”
• “Realistic for us to act on in practice”
Evaluation
• In short-term we will be monitoring impact on SSS
• Longer-term, Newcastle Uni will be tracking birth outcomes:
• Overall, we will monitor elements such as:
o
o
o
o
o
o
o
o
Percentage of women at booking who have a CO screening
Percentage of women who opt out at screening
The number of referrals into Stop Smoking Services
Conversion of referrals in to quit dates set
Quit success rates and the type of support received
Number of women who received the Risk Perception Intervention
Smoking at Time of Delivery rates
Birth outcomes (average birth weight, number of pre-term births)
Initial results
• Gateshead, South Tyneside & Sunderland (Cluster 2)
• Results for May 2013. SATOD for Q4 2012/13 in blue
Locality
Total
CO
Number of
smokers
Number
unable to
contact
Number
declining
support
Number
engaged
51
24
(47%)
7
0
17
(71%)
122
59
(48%)
25
3
31
(53%)
Sunderland
19.1%
94
35
(37%)
7
2
26
(74%)
Total Cluster
267
118
(44%)
39
5
74
(63%)
screening
Gateshead
15.4%
South
Tyneside
25.2%
Initial results
• Durham & Darlington (Cluster 1)
• SATOD Q4 2012/13: Durham 20.4% Darlington 23%
• Training Dec 12/Jan 13 (98 midwifery staff)
• Results for January–March 2013
• Total CO screening
1,366
• Number of smokers
432 (31.6%)
• Number of opt outs
(81 from five midwives)
195 (18.8%)
Initial results
• CO Screenings
1,366
• Referrals from midwives
430
• Referrals with CO at booking
237
• < 3 ppm
36
(15.2%)
•
4 – 10 ppm
81
(34.2%)
• 11 – 19 ppm
89
(37.5%)
• > 20 ppm
31
(13.1%)
Initial results
Covering period of May 2013 only
Lessons learnt
•Getting all key partners around the table was crucial in
focussing minds on this topic
•Initial research work was vital, as we could start discussions
with “we are addressing the issues that YOU identified”
•Independent evaluation gives the project legitimacy with
strategic partners and helped secure significant SHA funding
•Not everyone will embrace change initially. Work with the
willing, and convince the rest by delivering what you promise
•Important to work with admin / call centre staff about how they
approach women to convert an opt out referral into an
appointment with a Stop Smoking Advisor
Lessons learnt
• Balancing operational necessity with evaluation robustness:
o Randomised order of roll-out
o Speed of implementation vs. need for qualitative
evaluation
• Implementing major change across multiple localities in the
real world is hard:
o Significant organisational change happening
o People feel threatened by change
o All clusters have very different models to work with
o Have to be flexible around what elements are vital and
what is up for discussion
Lessons learnt
• Logistical problems of delivering training across a region to
hundreds of staff
• Supplying resources as part of the project was crucial in
getting people on-board
• Implementing systems for monitoring and evaluating
outcomes as well as performance management is essential
• The importance of a whole systems approach
Contact us…..
info@freshne.com
0191 333 7140
www.freshne.com
https://twitter.com/freshsmokefree
www.facebook.com/freshsmokefree
hwareing@pmaresearch.co.uk
01926 490 111