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 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. 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

7. 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 babyClear systematic approach

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: o Percentage of women at booking who have a CO screening o Percentage of women who opt out at screening o The number of referrals into Stop Smoking Services o Conversion of referrals in to quit dates set o Quit success rates and the type of support received o Number of women who received the Risk Perception Intervention o Smoking at Time of Delivery rates o 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 LocalityTotal CO screening Number of smokers Number unable to contact Number declining support Number engaged Gateshead 15.4% 5124 (47%) 7017 (71%) South Tyneside 25.2% 12259 (48%) 25331 (53%) Sunderland 19.1% 9435 (37%) 7226 (74%) Total Cluster267118 (44%) 39574 (63%)

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 ppm89 (37.5%) > 20 ppm31(13.1%)

17. Initial results Covering 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: 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

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