babyClear The North East`s regional approach to reducing maternal smoking rates

1. 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

2. 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

3. Why we have a focus on this

4. 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…..

5. 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

6. 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

7. 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

8. 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)

9. 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

10. 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”

11. 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”

12. 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”

13. 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: • 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)

14. Initial results • Gateshead, South Tyneside & Sunderland (Cluster 2) • Results for May 2013. SATOD for Q4 2012/13 in blue

15. 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 195 (18.8%) (81 from five midwives)

16. 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%)

17. Initial resultsCovering period of May 2013 only

18. 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

19. Lessons learnt • Balancing operational necessity with evaluation robustness: • Randomised order of roll-out • Speed of implementation vs. need for qualitative evaluation • Implementing major change across multiple localities in the real world is hard: • Significant organisational change happening • People feel threatened by change • All clusters have very different models to work with • Have to be flexible around what elements are vital and what is up for discussion

20. 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

21. 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