This article was downloaded by: [Computing & Library Services, University of Huddersfield]On: 05 October 2014, At: 09:04Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Social Work in Health CarePublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/wshc20

If Mothers Had Their Say: Research-Informed Intervention Design forEmpowering Mothers to Establish Smoke-Free HomesAudrey L. Begun PhDa, Sheila M. Barnhart MSWa, Thomas K. GregoirePhDa & Edward G. Shepherd MDb

a College of Social Work, Ohio State University, Columbus, Ohio, USAb College of Medicine, Ohio State University, Neonatology andNationwide Children’s Hospital, Columbus, Ohio, USAPublished online: 16 May 2014.

To cite this article: Audrey L. Begun PhD, Sheila M. Barnhart MSW, Thomas K. Gregoire PhD &Edward G. Shepherd MD (2014) If Mothers Had Their Say: Research-Informed Intervention Design forEmpowering Mothers to Establish Smoke-Free Homes, Social Work in Health Care, 53:5, 446-459, DOI:10.1080/00981389.2014.888125

To link to this article: http://dx.doi.org/10.1080/00981389.2014.888125

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &

Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Dow

nloa

ded

by [

Com

putin

g &

Lib

rary

Ser

vice

s, U

nive

rsity

of

Hud

ders

fiel

d] a

t 09:

04 0

5 O

ctob

er 2

014

Social Work in Health Care, 53:446–459, 2014Copyright © Taylor & Francis Group, LLCISSN: 0098-1389 print/1541-034X onlineDOI: 10.1080/00981389.2014.888125

If Mothers Had Their Say: Research-InformedIntervention Design for Empowering Mothers

to Establish Smoke-Free Homes

AUDREY L. BEGUN, PhD, SHEILA M. BARNHART, MSW,and THOMAS K. GREGOIRE, PhD

College of Social Work, Ohio State University, Columbus, Ohio, USA

EDWARD G. SHEPHERD, MDCollege of Medicine, Ohio State University, Neonatology and Nationwide Children’s Hospital,

Columbus, Ohio, USA

The Empowering Mothers to Establish Smoke-free Homes (EMESH)project developed in response to an interdisciplinary health teamseeking effective interventions for reducing/eliminating the envi-ronmental tobacco smoke exposure of infants with compromisedrespiratory status. Two study phases that informed the EMESHintervention design are described. Phase I involved semi-struc-tured interviews with 20 caretakers of infants diagnosed withBronchopulmonary Dysplasia (BPD). In Phase II, 75 randomlyselected medical records of infants with BPD were reviewed toexplore the family demographics and staff behavior regarding envi-ronmental tobacco smoke (ETS) interventions. Interview resultssuggest that families are open to partnering with social workersand interdisciplinary team members in addressing infants’ ETSexposure, families’ unique circumstances indicate a need for tai-lored interventions, and the use of self-efficacy and decisionalbalance tools are feasible options. Results from the medical recordsreview indicate that many families are economically vulnerableand reside in regions where smoking is common. There is a paucityof staff documentation regarding ETS conversations and inter-ventions, indicating that these conversations may not take place.Together these results suggest a two-pronged approach in the nextphases of EMESH: staff training in hosting and documenting ETS

Received October 16, 2013; accepted January 23, 2014.Address correspondence to Audrey L. Begun, Ohio State University, College of Social

Work, 325 Stillman Hall, 1947 College Rd., Columbus, OH 43210. E-mail: begun.5@osu.edu

446

Dow

nloa

ded

by [

Com

putin

g &

Lib

rary

Ser

vice

s, U

nive

rsity

of

Hud

ders

fiel

d] a

t 09:

04 0

5 O

ctob

er 2

014

If Mothers Had Their Say: EMESH 447

conversations and a tailored, parent-driven set of interventionoptions.

KEYWORDS reducing tobacco smoke exposure, researchinformed intervention, intervention research, bronchopulmonarydysplasia, neonatal intensive care

Preventing hospitalization and a need for acute medical care among infantsand children is an important priority for economic, human resource, andhumanitarian reasons. Social workers have much to offer in response. Onesignificant objective toward this goal involves reducing infant and child expo-sure to environmental tobacco smoke (ETS) and tobacco smoke residue(TSR). ETS involves spending time in a space where someone else wassmoking, and is often referred to as passive or second-hand smoke exposure(Environmental Protection Agency [EPA], 2011; Windham, Eaton, & Hopkins,1999). TSR describes “third-hand” exposure to contaminant residues left inthe air and on surfaces (Winickoff et al., 2009), even well after the tobaccosmoke has dissipated. The Healthy People 2020 initiatives specifically addressthe reduction of illness, disability, and death related to non-smokers’ ETSexposure, with a specific emphasis on children (TU-11; USDHHS, 2010). TSRexposure is equally as concerning (Winickoff et al., 2009).

Infants’ and children’s ETS and TSR exposure in their own homes isunfortunately common according to literature citing data from the late 1990sto early 2000s. More than a third (34.4%) of children in the United Stateslived with one or more adults who smoked (King et al., 2009), and 11% ofchildren aged six and under (almost three million) were exposed to ETS ona regular basis at home (EPA, 2003). Children with the greatest likelihood ofETS exposure in the home were from households living below the federalpoverty level (King et al., 2009). Recent large-scale epidemiological studiesare absent in the literature.

The Surgeon General’s Report (USDHHS, 2006, p. 137) noted thatbetween 1994 and 1998, the percentage of children aged six years andyounger with regular ETS exposure at home declined, and the number ofhouseholds prohibiting smoking increased between 1993 and 1999. Evidencealso suggests that the public health gains associated with efforts to reduceAmericans’ ETS exposure have been greater among adults than children.Biomarkers for children’s ETS exposure show that declines in averageamounts of exposure are not as rapid as are declines among adults over10 years ending during the early 2000s (Williamson, 2010).

Young children are particularly vulnerable to TSR because of theirclose proximity to contaminated surfaces from playing and crawling onfloors/carpets, as well as touching and mouthing objects (Baxter et al., 2011;Winickoff et al., 2009). In households where parents protectively smoked

Dow

nloa

ded

by [

Com

putin

g &

Lib

rary

Ser

vice

s, U

nive

rsity

of

Hud

ders

fiel

d] a

t 09:

04 0

5 O

ctob

er 2

014

448 A. L. Begun et al.

outdoors, ETS and TSR levels still measured five- to seven-times higher thanin non-smoking households; TSR was three time greater in households wheresmoking occurred indoors than in outdoors-only smoking (Matt et al., 2004).

ETS and TSR exposure include a wide range of consequences. Thistype of exposure appears to be linked to sudden infant death syndrome(SIDS), respiratory infections, pneumonia, bronchitis, asthma, slowed lunggrowth, and other respiratory symptoms, as well as ear infections (Bock,Becker, & Borrelli, 2008; DiFranza, Aligne, & Weitzman, 2004; USDHHS,2006). Household ETS exposure during a child’s first six months of life hasbeen associated with an increase in the probability of hospitalization—a vul-nerability still present at eight years of age, and especially compelling amongbabies born prematurely (Kwok et al., 2008). Prenatal and post-birth expo-sure to parental smoking have been associated with children’s neurological,cognitive, and behavioral problems (DiFranza et al., 2004; Herrmann, King,& Weitzman, 2008; Yolton et al., 2008). In fact, children’s later reading scoresappear more strongly affected by ETS exposure than by prenatal tobaccosmoke exposure, birth weight, and staying in the neonatal intensive careunit (NICU) (Yolton, Dietrich, Auinger, Lanphear, & Homung, 2005).

While the effects of ETS and TSR exposure are harmful for all infantsand children (Hannöver et al., 2008), risks are compounded for babies whoexperience respiratory complications at or shortly following birth, requiringNICU support (Bock et al., 2008; Stotts et al., 2011). Many babies who beginlife needing NICU care develop chronic conditions affecting their respira-tory health (Manktelow, Draper, Annamalai, & Field, 2001; Schrader, Czajka,Kalman & McGeady, 1998). In the United States, the estimated smoking-attributable neonatal expenditure was over $148.5 million in 2003 (Centersfor Disease Control and Prevention [CDC], 2011).

Babies in the NICU born preterm and/or with low birth weight areparticularly susceptible to developing the type of chronic respiratory com-plication diagnosed as bronchopulmonary dysplasia (BPD), experienced byabout 22% of these infants (Stotts et al., 2011). In turn, infants with BPD havean increased probability of experiencing repeated hospitalizations and needfor acute medical care due to a host of smoke-exacerbated health complica-tions (Stotts et al., 2011). Adverse economic, social, emotional, psychological,and family effects are sources of concern related to social work practice withthese particularly vulnerable infants and children.

EMPOWERING MOTHERS TO ESTABLISH SMOKE-FREEHOMES (EMESH)

The interdisciplinary EMESH Project was developed to help health care teamsaddress infants’ ETS and TSR exposure in their home and automobile envi-ronments. The ETS and TSR exposure derives from multiple sources, not all

Dow

nloa

ded

by [

Com

putin

g &

Lib

rary

Ser

vice

s, U

nive

rsity

of

Hud

ders

fiel

d] a

t 09:

04 0

5 O

ctob

er 2

014

If Mothers Had Their Say: EMESH 449

of which are in the immediate and direct control of a parent. First, a parentmay smoke cigarettes in the home and car, exposing the infant to both sec-ond hand smoke and third hand smoke residue. However, successful quitattempts are difficult to achieve, and many available tools are not accessi-ble in some communities and the expenses may exceed a family’s means.Furthermore, many individuals experience great difficulty in quitting smok-ing under general circumstances; it may not be realistic to expect a parent tosucceed in a quit attempt during the stressful periods associated with caringfor a newborn, much less a newborn with serious medical and/or devel-opmental challenges. Harm reduction efforts involving smoking outdoors,cleaning hands, and changing clothing may be only partially responsive tothe situation, and may not suffice to prevent the infant from experiencingrepeated complications. Second, the parents may be non-smokers but theinfant may be exposed through other family members, family friends, ordaycare providers; parents may depend on these individuals for child careor housing, depending on their economic or geographic resource limitations.Third, the source of exposure may be residue from past smoke in the homeor car, or from neighbors in a poorly ventilated apartment complex.

Consistent with social work values, EMESH promotes self-determinationin selecting from among a list of intervention options. The “menu-driven”model is designed to foster parents’ empowerment for making change intheir infants’ ETS and TSR exposure, guided by the three principle compo-nents of evidence-based practice: integrating practitioner expertise, clientpreferences, and best-practice evidence (McNeece & Thyer, 2004). TheEMESH model recognizes the relative uniqueness of each family’s experi-ences, needs, and resources; hence, interventions related to ETS and TSRexposure need to be individually tailored.

The model also recognizes that a family’s circumstances change overtime, necessitating adaptation in the services engaged. This dynamic, devel-opmental perspective is informed by the transtheoretical model of behavioralchange (TMBC), evolving from smoking cessation science (Prochaska,DiClemente, & Norcross, 1992). Specifically, it is expected that, over time,individuals will experience differing levels of self-efficacy and fluctuationsin their decisional-balance for making the required changes. The TMBCframework incorporates recommendations concerning clinical behaviors bestmatched to different expressions of self-efficacy and decision-balance asso-ciate with dynamic stages in the change process (Connors, Donovan, &DiClemente, 2001).

The following article describes two sources of data utilized to informthe EMESH model. In the first phase, qualitative interview data informed themenu of options and implementation details. In the second phase, infants’medical records were reviewed to inform the project about the populationto be served, as well as staff behaviors related ETS and TSR intervention.

Dow

nloa

ded

by [

Com

putin

g &

Lib

rary

Ser

vice

s, U

nive

rsity

of

Hud

ders

fiel

d] a

t 09:

04 0

5 O

ctob

er 2

014

450 A. L. Begun et al.

Implications for social work and interdisciplinary teams utilizing similarsources of information in developing behavioral health interventions arediscussed.

METHODS

The two study phases, Phase I and Phase II, each involved a distinct method-ology in light of their distinct study aims. Phase I applied an exploratory,qualitative, single-interview research design addressing changes related toreducing infants’ exposure to ETS and TSR, regardless of the sources ofexposure. Phase II was a secondary data analysis of infants’ electronic med-ical records. Study procedures were approved by the collaborating partners’Institutional Review Boards (IRBs).

Participants: Phase I

Phase I study participants included 20 mothers/primary caregivers to infantswith BPD diagnoses, receiving treatment in the neonatal intensive care unit(NICU) or in the BPD follow-up clinics at Nationwide Children’s hospital.Participants were recruited as a convenience sample through informationalflyers describing the purpose and confidentiality of the voluntary study.Inclusion criteria were being a mother/primary caregiver to a baby with aBPD diagnosis, in the NICU during the past 24 months, and living in a homewith current or past smokers, regardless of which family members might bethe potential sources for an infant’s ETS or TSR exposure. Participants wereprovided with a $10 gift card.

Measurement and Procedures: Phase I

Data collection proceeded through semi-structured individual interviewsconducted by trained female interviewers, in the infant’s hospital or clinicexamination room. The interview included seven questions with scriptedprompts, and lasted 10–15 minutes. Participants were asked to: (a) sug-gest important elements that they would recommend including in a menuof options for helping establish smoke-free homes; (b) identify decisionalbalance factors that might encourage either changing or not changing behav-ior associated with babies’ ETS/TSR exposure; (c) rate their self-efficacy formaking the baby’s environment smoke-free; (d) identify the ideal timing ofintervention; and (e) react to peer mentors being part of the interventionteam. Interviews were transcribed from digital audio-recordings. Contents ofinterview transcripts were thematically coded by a single reviewer with theevolving coding scheme being cross-checked daily with a second reviewer.

Dow

nloa

ded

by [

Com

putin

g &

Lib

rary

Ser

vice

s, U

nive

rsity

of

Hud

ders

fiel

d] a

t 09:

04 0

5 O

ctob

er 2

014

If Mothers Had Their Say: EMESH 451

Participants: Phase II

Secondary analysis was conducted with 75 electronic medical recordsrandomly selected from a master list of 240 infants hospitalized with aBPD diagnosis at least once in the NICU between January 1, 2009 andDecember 31, 2011. The reviewed records included 49 boys (63%) and26 girls (35%), ranging in age from 5 to 59 months (M = 25.05, SD =11 months). Almost all families were English-speaking (93%).

Measurement and Procedures: Phase II

In addition to demographic data, the infant’s county of residence was used toreport the following aspects of family context: the county’s median house-hold income status and county-level smoking rates (derived from profilespublished by the Ohio Department of Health [ODH], 2008). For purposesof case de-identification, low-incidence values on some variables werecollapsed. Infant-specific data included the numbers of hospitalizations, inpa-tient days, and BPD clinic visits. Additionally, a total of 106,294 history andprogress notes recorded by physician, nursing, and social work staff (M perinfant = 1,436.4 notes, SD = 819.31) were reviewed to code whether or not:mother smoked during pregnancy, mother smoked after baby’s birth, infantlived with a smoker other than mother, staff addressed smoking behavior,ETS exposure information was provided, and mother or caretaker was linkedwith smoking cessation services. Coder reliability was checked by duplicatecoding for 12% of randomly selected cases.

RESULTS

Phase I Results

Participants’ responses to the first question regarding important elementsto include in the menu of intervention options represented seven cate-gories. The majority of respondents welcomed the idea of receiving ETSreduction/elimination education and tools (see Table 1).

With regard to the decisional balance favoring making changes for asmoke-free home, responses primarily emphasized health: healthier infants,families, and environment. There was also a body of responses identifyingpersonal gains in self-confidence and self-respect from establishing a smoke-free home. On the flip side of decisional balance, responses to a questionregarding forces for “leaving things as they are” included attitude factors suchas not caring, being selfish, or having apathy.

The question regarding self-efficacy for establishing a smoke-free homeelicited high estimates of the participants’ self-efficacy for achieving this goal:eleven participants offered ratings of 8–10, five offered ratings around 7, two

Dow

nloa

ded

by [

Com

putin

g &

Lib

rary

Ser

vice

s, U

nive

rsity

of

Hud

ders

fiel

d] a

t 09:

04 0

5 O

ctob

er 2

014

452 A. L. Begun et al.

TABLE 1 Response Category for Three Questions, Listed by Frequency of Response Type

Question and response categories Frequency

1. Menu of optionsa Provide education/educational tools/educational resources 19b Provide smoking cessation resources/access to programs

(electronic cigarettes, nicotine patches, financial incentives toquit)

14

c Provide resources for/assist in ETS and TSR reduction/cleanup (home, car)

7

d Coach people how to talk to others about not smokingaround children

5

e Target young children with anti-smoking education 1

2. Important and rewarding outcomes for making your baby’s environments smoke-freea Better health (child, infant, everyone) 26b Cleaner home/environment 6c Gaining self-confidence and self-respect 5d Financial advantage of eliminating expenditure on smoking

products3

e Smelling better 3f Being a role model for children and others/being a positive

influence1

g Increased visitors from persons who avoid homes withETS/TSR

1

h Improved relationships with others 1

3. What makes mothers want to leave things as they are in the babies’ environmentsb Attitude: apathy/selfishness/indifference 9a Unaware of smoking-related consequences 7h Emotional and physical gratification from smoking/smoking

as coping mechanism/boredom6

g Difficulty of quitting smoking/physical addiction to cigarettes 5c Fear of confronting other who is a smoker 4d Lacking resources to quit or help other quit smoking 3e Influence from other who smokes/cohabitant refuses to quit

smoking3

f Jeopardizing relationships 1i Mental illness 1

Responses for N = 20 interviews, more than one response possible each interview.

had ratings of 4 or lower, and two did not offer a response. In two cases afather or grandmother challenged the mother’s rating with a much lower rat-ing because of their own smoking, not the mother’s behavior. The mothers’comments included indications that they imposed strict rules about smok-ing and cleaning up after smoking, before coming in contact with the baby.For example, “I keep it just like he was in the NICU still.” “We just don’tallow it.” “And, if they are not going to do it, they’re not going to be aroundhim.” The mothers’ comments also included some doubts introduced bysituations when they are not around, such as at day care, in the care of rela-tives, and so forth. The mothers with the two low efficacy scores describedboth intense struggles and little intent to change their own smoking andquit-related behaviors.

Dow

nloa

ded

by [

Com

putin

g &

Lib

rary

Ser

vice

s, U

nive

rsity

of

Hud

ders

fiel

d] a

t 09:

04 0

5 O

ctob

er 2

014

If Mothers Had Their Say: EMESH 453

With regard to timing of intervention in relation to the baby’s hospitaliza-tion, responses generally reflected early and continuous offers of interventionoptions; six responses indicated that it needed to start while the motherwas still pregnant. However, three mothers indicated that it should not beintroduced too early because they needed a chance to settle into having aninfant, an infant in the NICU, and an infant discharged from the NICU. “It isan incredibly stressful thing to go through, and that is definitely not a timeto hit somebody up!” “After they have felt comfortable, you know what Imean? I think it helps a lot, just being comfortable in the situation.” Relatingthe timing to preparation for discharge was a suggested alternative: “Like atthe end of the hospitalization.” “You need to know the person, and thenask them. Ask them to think about it, and then she will think about it, andthen possibly do it.” “I would make sure they was educated before they left.So make sure before they was discharged.”

In response to the idea that “other mothers like you” might be helpful inmaking the changes needed to establish a smoke-free home, 13 participantswere very much in favor of the peer mentor model. “No one will ever knowwhat it’s like to be in your position, so, yeah. Someone who’s been there,and done that, because a lot of professionals haven’t.. . .Sorry! (laughs). It’svery hard to talk to someone about quitting an addiction if you’ve never hadthat problem before.” Five others who were less enthusiastic but still positiveabout the idea, and the one with a negative response, expressed concernssuch as: “Quitting an addiction is a very personal thing, and other peopleare not going to be able to help.” “People don’t want to be preached to,right?” One mother expressed her belief that professionals who specializein this topic can do a better job and have more teaching/helping resourcescompared to peers.

The final interview item asked mothers to provide any additional adviceor comments. Responses ranged from imposing legislation to ban smok-ing around infants and children, making programs voluntary, acknowledgeeach person’s uniqueness and emotional state, offer home-based servicesand literature sent home, and help people cut back/set limits.

Phase II Results

The mean number of hospital admissions these infants experienced was 2.59(range = 1–11; SD = 2.11), their mean number of hospitalized days equaled133 (range = 1–596 days; SD = 105 days), and their mean number of BPDoutpatient clinic visits was 6.82 (range = 0–19; SD = 3.91). The major-ity of the infants were male (65.3%). They were predominantly Caucasian(61.3%) and non-Hispanic (89.3%). Over 60% of these infants received healthcare coverage through a government sponsored insurance program, and amajority (77.3%) resided within 0 to 60 miles of the hospital where they hadreceived inpatient BPD services (see Table 2).

Dow

nloa

ded

by [

Com

putin

g &

Lib

rary

Ser

vice

s, U

nive

rsity

of

Hud

ders

fiel

d] a

t 09:

04 0

5 O

ctob

er 2

014

454 A. L. Begun et al.

TABLE 2 Distribution for 75 Infants on Variables Identified in Phase II

Variable Frequency Percent

RaceAsian Other 2 2.7Black/African American 18 24.0Other 3 4.0Two or More Races 3 4.0Unknown 3 4.0White/ Caucasian 46 61.3

EthnicityHispanic/Latino 3 4.0Non-Hispanic/Non-Latino 67 89.3Other 5 6.7

Primary Insurance Source 26 34.7Private/ Commercial 48 64.0Government 1 1.3No Insurance

Mean SD (range)Hospital Admissions 2.59 2.11 (1–11)Hospitalized Days 132.96 105.06 (1–596)BPD Clinic Visits 6.82 3.91 (0–19)

Among the 70 infants residing in-state, 79% lived in counties wheremedian household incomes ranged between $40,000 and $49,000, and 74%resided in counties with poverty rates over 15% (ODH, 2008). In theinfants’ counties of residence, maternal and general population currentcigarette smoking rates varied: 54% lived in counties where maternal smok-ing rates were in the 6–15% range, 24% lived where maternal smokingrates were in the 16–24% range, and 21% lived where maternal smok-ing rates were in a range of 25% or greater. The majority (90%) of theinfants came from counties where the general adult population smok-ing rate was 6–25%, with the remainder coming from counties where26–35% of adults smoke (ODH, 2008). Finally, the major proportion ofthese infants lived in counties classified as primarily urban (74%) asdefined by the United States Office of Management and Budget (USDA,2012).

The review of infant medical records indicated a substantial amountof missing information regarding the smoking behavior of family members(Table 3). Whereas 21.3% of the records contained notes indicating that aninfant’s mothers smoked during pregnancy, 65.3% of the records providedno information, positive or negative, regarding prenatal smoke exposure.The majority of the reviewed medical records (61.3%) contained no notesconcerning whether or not the infants lived with someone who smoked.In addition, a few records reflected overt inconsistencies: within the samerecord, one note reported that there was smoke exposure in the baby’shome, while others reported that there was none. An additional few records

Dow

nloa

ded

by [

Com

putin

g &

Lib

rary

Ser

vice

s, U

nive

rsity

of

Hud

ders

fiel

d] a

t 09:

04 0

5 O

ctob

er 2

014

If Mothers Had Their Say: EMESH 455

TABLE 3 Parent and Staff Behavior in Staff Documentation

Variable Frequency Percent

Patient’s Mother Smoked During PregnancyYes 16 21.3No 10 13.3Unknown 49 65.3

Patient’s Mother Smoked After Patient’s BirthYes 10 13.3No 19 25.3Unknown 46 61.3

Patient Lives with Smoker Other Than MotherYes 11 14.7No 18 24.0Unknown 46 61.3

Staff Has Addressed Smoking with ParentYes 15 20.0No 9 12.0Unknown 51 68.0

Staff Provided ETS EducationYes 18 24.0No 5 6.7Unknown 52 69.3

Mother Linked With Smoking Cessation ProgramYes 0 0No 11 14.7Unknown 64 85.0

contained clinical notes describing ETS conversations with parents charac-terized as confrontational—that parents’ responses were defensive or endedin conflict.

Staff behavior with regard to discussing ETS and TSR was difficult tosummarize because 68% of the medical records contained no notes indi-cating whether or not a staff member (physician, nurse, or social worker)addressed smoking behavior with the infant’s parent/caretaker, 69.3% lackednotes reporting whether or not staff provided ETS/TSR education to theparent/caretaker, and 85% did not reveal whether or not the mother/caretaker was linked with a smoking cessation program. Due to the high pro-portion of records without documentation on the staff behaviors of interest,no comparative statistical analyses were conducted.

DISCUSSION

The results of these two study phases help inform the development of next-step intervention protocols. First, parents seem to be open to partneringwith health care teams around reducing their infants’ ETS and TSR expo-sure. This is encouraging, because evidence suggests that a key reason why

Dow

nloa

ded

by [

Com

putin

g &

Lib

rary

Ser

vice

s, U

nive

rsity

of

Hud

ders

fiel

d] a

t 09:

04 0

5 O

ctob

er 2

014

456 A. L. Begun et al.

health providers avoid these conversations is their concern that parents willreact negatively to questions or advice about smoking (Frankowski, Weaver,& Secker-Walker, 1993). This finding supports earlier literature that bothsmoking and non-smoking parents respond positively to being asked aboutsmoking behavior and receiving advice (Cluss & Moss, 2002). Second, resultsindicate that parents can offer valuable insights in terms of both active ingre-dients and implementation of interventions designed to help them promotesmoke-free environments for their infants. Third, the use of self-efficacy anddecisional balance tools reflected in three of the qualitative questions maybe valuable in helping assess needs and resources for change regarding ETSand TSR exposure. However, future investigators are advised to considerthe potential influence of social desirability with the use of these clinicaltools. These three outcomes relate to the EMESH Project objectives promot-ing parental empowerment and self-determination in their efforts for makingchange in infants’ ETS and TSR exposure.

Phase II results indicate several important points for social workers toconsider. Regarding the serious lack of documentation about ETS/TSR com-munication with parents, two possible explanations warrant further attention.On one hand, the critical ETS reduction conversations recommended bythe American Academy of Pediatrics and the U.S. Surgeon General (Collins,Levin, & Bryant-Stephens, 2007) may not be happening. In addition to timeconstraints, this may be attributed to a lack of confidence in their sense ofcompetence for providing this advice (Cluss & Moss, 2002; Collins et al.,2007). One implication for social workers is to offer training to the interdisci-plinary team about engaging in difficult behavior-change conversations. Theresults concerning conflict and parents’ defensiveness in response to profes-sionals’ discussions about ETS lend further support to this recommendation.On the other hand, social workers and other health care professionals maynot be including in their documentation information about their ETS/TSRconversations. This is problematic in that families are best served whenteam members communicate (via documentation), thereby affording eachother the opportunity to build on previous interactions, without becom-ing repetitious. Social workers may engage as change agents around thesedocumentation concerns; for example, future staff training and develop-ment efforts directed specifically toward improved, systematic, uniformdocumentation standards appears warranted.

Phase II results also indicate the potential importance of social con-text dimensions in ETS and TSR exposure: a perspective that social workprofessionals can bring to interdisciplinary teams. The infants served inthis setting often come from communities where smoking in general,and maternal smoking specifically, may be normatively situated. Manyalso come from communities with low levels of economic resources andfamilies depending on public funds for health care services. Evidencesuggests that tobacco cessation initiatives currently struggle “to do more

Dow

nloa

ded

by [

Com

putin

g &

Lib

rary

Ser

vice

s, U

nive

rsity

of

Hud

ders

fiel

d] a

t 09:

04 0

5 O

ctob

er 2

014

If Mothers Had Their Say: EMESH 457

with less” in terms of meeting public health mandates in an environ-ment of scarce funding (www.healthohioprogram.org/en/healthylife/tobc2/qsmoking/collaborative.aspx). Families may not be able to afford ETS/TSRreduction aids that each identifies as being most beneficial to them, hav-ing to rely instead on less directly relevant resources or no resources at all.Addressing resource concern is, yet again, an important social work role inhealth care systems.

The next phases of EMESH, informed by these earlier phases, willinclude developing and testing staff development interventions. Responsesto these reported results from clinic and hospital staff leadership confirmedthat training about means for effectively engaging parents in these difficultETS and TSR conversations would be a valuable strategy to increase thefrequency and improve the quality of these conversations. Developing andtesting the ETS/TSR intervention menu of options will proceed in next phasesof the EMESH Project guided by a combination of social work, nursing, andmedicine professionals’ input, along with the contributions from these par-ents. The menus will be validated through focus group methodologies priorto implementation and testing. The generalizable principle for social workersengaging in health intervention research is that these first two steps repre-sent important, informative phases of intervention development—prior toinitiating efficacy and effectiveness trials.

REFERENCES

Baxter, S., Blank, L., Everson-Hock, E.S., Burrows, J., Messina, J., GuillaUme, L., &Goyder, E. (2011). The effectiveness of interventions to establish smoke-freehomes in pregnancy and in the neonatal period: A systematic review. HealthEducation Research, 26(2), 265–282.

Bock, B.C., Becker, B.M., & Borelli, B. (2008). Smoking behavior and risk perceptionamong the parents of infants in the neonatal intensive care unit. Nicotine andTobacco Research, 10(1), 47–54.

Centers for Disease Control and Prevention (CDC). (2011). Smoking-attributable mor-tality, morbidity, and economic costs, maternal and child health computation(MCH SAMMEC). Interactive computation based on 2003 data. Retrieved fromhttps://apps.nccd.cdc.gov/sammec/mch_dhccexp.asp

Cluss, P.A., & Moss, D. (2002). Parent attitudes about pediatricians addressingparental smoking. Ambulatory Pediatrics, 6(2), 485–488.

Collins, B.N., Levin, K.P., & Bryant-Stephens, T. (2007). Pediatrician’s practicesand attitudes about environmental tobacco smoke and parental smoking. TheJournal of Pediatrics, 150(5), 547–552.

Connors, G.J., Donovan, D.M., & DiClemente, C.C. (2001). Substance abuse treat-ment and the stages of change: Selecting and planning interventions. New York,NY: Guilford Press.

Dow

nloa

ded

by [

Com

putin

g &

Lib

rary

Ser

vice

s, U

nive

rsity

of

Hud

ders

fiel

d] a

t 09:

04 0

5 O

ctob

er 2

014

458 A. L. Begun et al.

DiFranza, J.R., Aligne, C.A., & Weitzman, M. (2004). Prenatal and postnatal envi-ronmental tobacco smoke exposure and children’s health. Pediatrics, 113(4),S1007–S1015.

Environmental Protection Agency (EPA). (2003). Fact sheet: National survey on envi-ronmental management of asthma and children’s exposure to environmentaltobacco smoke. Retrieved from www.epa.gov/smokefre/pdfs/survey_fact_sheet.pdf

Environmental Protection Agency (EPA). (2011). Health effects of exposure to sec-ondhand smoke. Retrieved from www.epa.gov/smokefree/healtheffects.htmlRetrieved on 6/18/13

Frankowski, B.L., Weaver, S.O., & Secker-Walker, R.H. (1993). Advising parents tostop smoking: Pediatricians’ and parents’ attitudes. Pediatrics, 91(2), 296–300.

Hannöver, W., Rhyrian, J.R., Ebner, A., Roske, K., Grempler, J., Kuhl, R., . . .& John,U. (2008). Smoking during pregnancy and postpartum: Smoking rates and inten-tion to quit smoking or resume after pregnancy. Journal of Women’s Health,17(4), 631–640.

Herrmann, M., King, K., & Weitzman, M. (2008). Prenatal tobacco smoke and postna-tal secondhand smoke exposure and child neurodevelopment. Current Opinionin Pediatrics, 20(2), 184–190.

King, K., Marynenko, M., Bergman, M.H., Ying-Hua, L., Winickof, J.P., & Weitzman,M. (2009). Family composition and children’s exposure to adult smokers in theirhomes. Pediatrics, 123(4), e559–e564.

Kwok, M.K., Schooling, C.M., Ho, L.M., Leung, S.S., Mak, K.H., McGhee, S.M., . . .

&Leung, G.M. (2008). Early life second-hand smoke exposure and serious infec-tious morbidity during the first 8 years: Evidence from Hong Kong’s “Childrenof 1997” birth cohort. Tobacco Control, 17 , 263–270.

Manktelow, B.N., Draper, E.S., Annamalai, S., & Field, D. (2001). Factors affectingthe incidence of chronic lung disease of prematurity in 1987, 1992, and 1997.Archives of Disease in Childhood, 85, F33–F35.

Matt, G.E., Quintana, P.J.E., Hovell, M.F., Bernert, J.T., Song, S., Novianti, N., . . .

&Larson, S. (2004). Households contaminated by environmental tobacco smoke:Sources of infant exposure. Tobacco Control, 13, 29–37.

McNeece, C.A., & Thyer, B.A. (2004). Evidence-based practice and social work.Journal of Evidence-Based Social Work, 1(1), 7–25.

Ohio Department of Health (ODH). (2008). Healthy Ohio community pro-files. Office of Healthy Ohio, Columbus, OH. Retrieved from http://www.healthyohioprogram.org/resources/datareports/profiles.aspx

Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992). In search of how peo-ple change: Applications to addictive behaviors. American Psychologist, 47(9),1102–1114.

Schrader, B.D., Czajka, C., Kalman, D.D., & McGeady, S.J. (1998). Respiratory health,lung function, and airway responsiveness in school-age survivors of very-low-birth-weight. Clinical Pediatrics, 37 , 237–246.

Stotts, A.L., Evans, P.W., Green, C.E., Northrup, T.F., Dodrill, C.L., Fox, J.M., . . .

&Hovell, M.F. (2011). Secondhand smoke risk in infants discharged from anNICU: Potential for significant health disparities. Nicotine & Tobacco Research,13(11), 1015–1022.

Dow

nloa

ded

by [

Com

putin

g &

Lib

rary

Ser

vice

s, U

nive

rsity

of

Hud

ders

fiel

d] a

t 09:

04 0

5 O

ctob

er 2

014

If Mothers Had Their Say: EMESH 459

United States Department of Agriculture (USDA). (2012). Rural definitions: State-levelmaps. USDA Economic Research Services. Retrieved from http://www.ers.usda.gov/Data/RuralDefinitions/maps.htm

U.S. Department of Health and Human Services (USDHHS). (2006). The health con-sequences of involuntary exposure to tobacco smoke: A report of the SurgeonGeneral. Atlanta, GA: U.S. Dept. of Health and Human Services, Centers forDisease Control and Prevention, Coordinating Center for Health Promotion,National Center for Chronic Disease Prevention and Health Promotion, Officeon Smoking and Health. Retrieved from http://www.surgeongeneral.gov/library/reports/secondhandsmoke/report-index.html

U.S. Department of Health and Human Services (USDHHS). (2010). Healthy People2020. Office of Prevention and Health Promotion. Washington, DC. Retrievedfrom http://www.healthypeople.gov

Williamson, J.M. (2010). Environmental tobacco smoke and children’s health. EasternEconomic Journal, 36 , 423–449.

Windham, G.C., Eaton, A., & Hopkins, B. (1999). Evidence for an associa-tion between environmental tobacco smoke exposure and birth weight: Ameta-analysis and new data. Paediatric and Perinatal Epidemiology, 13(1),35–57.

Winickoff, J.P., Friebely, J., Tanski, S.E., Sherrod, C., Matt, G.E., Hovell, M.F., &McMillen, R.C. (2009). Beliefs about the health effects of ‘‘thirdhand’’ smoke andhome smoking bans. Pediatrics, 123, e74–e79. Retrieved from http://pediatrics.aappublications.org/content/123/1/e74.full.html

Yolton, K., Dietrich, K., Auinger, P., Lanphear, B.P., Homung, R. (2005). Exposure toenvironmental tobacco smoke and cognitive abilities among U.S. children andadolescents. Environmental Health Perspectives, 113(1), 98–103.

Yolton, K., Khoury, J., Hornung, R., Dietrich, K., Succop, P., & Lanphear, B.(2008). Environmental tobacco smoke exposure and child behaviors. Journalof Developmental & Behavioral Pediatrics, 29, 450–457.

Dow

nloa

ded

by [

Com

putin

g &

Lib

rary

Ser

vice

s, U

nive

rsity

of

Hud

ders

fiel

d] a

t 09:

04 0

5 O

ctob

er 2

014