Insert name of presentation on Master Slide Using a range of NHS staff to deliver stop smoking services to pregnant women: (preliminary) findings from.

Insert name of presentation on Master Slide

Using a range of NHS staff to deliver stop smoking services to pregnant women:

(preliminary) findings from the Models for Access to Maternal Smoking cessation

Support (MAMSS) study

12 June 2015

Mrs Lorna Bennett Specialty Registrar in Public HealthDr Aimee Grant Research Fellow

Overview• Smoking in pregnancy in Wales• Public health response: MAMSS project• Preliminary outcomes• Qualitative evaluation findings• Lessons learnt & conclusion

Models for Access to Maternal Smoking cessation Support (MAMSS)

Maternal smoking in UK

Models for Access to Maternal Smoking cessation Support (MAMSS)

Contacts to the Stop Smoking Wales service by pregnant women 1st April 2012 to 31st March 2013

% of pregnant smokers

(Estimated number of pregnant smokers = 6920)

Number scheduled appointment 944 14%

Number of treated smokers 144 2%

Number successfully quit at 4 weeks (self-reported)

52 0.01%

Number successfully quit at 4 weeks

(CO validated)

21 <0.01%

Service Outcomes 2012-13

Public Health Response: MAMSS• Design and deliver new service models for smoking cessation services for pregnant women

• Systematic implementation of NICE guidance in all areas

•Flexible, women-centred approach provided by: MSW or Midwife or Specialist stop smoking advisor for pregnant women

•Compare the effectiveness of the new models of service delivery with usual care

Models for Access to Maternal Smoking cessation Support (MAMSS)

Methods

• Four Health Boards in Wales

• Quasi-experimental design

• Intervention and usual care sites

• Outcome and process evaluationModels for Access to Maternal Smoking cessation Support (MAMSS)

•Referral from midwife to NHS Stop Smoking Service via fax or phone call.

•Stop smoking staff make an attempt to contact the pregnant women within 48 hours to discuss benefits of quitting, offer support and arrange an assessment session.

•NHS Stop Smoking Service staff attempt to contact the client by telephone twice more if contact has not been established, and send a follow up letter if no response.

•Referral from midwife to smoking cessation support within 48 hours

•MAMSS clinician attempts to contact pregnant woman by telephone (or face-to-face at clinic) within 48 hours to discuss support and to arrange an appointment for an assessment session.

•MAMSS clinician attempts to contact the client by telephone at least twice more if contact has not been established.

•Women are fast tracked into a one-to-one assessment session appointment within 48 hours. Assessment sessions are conducted in community venues. •Women are offered six further sessions of intensive behavioural support in community venues or by telephone, each lasting around 30 minutes. •Women are CO monitored at all treatment sessions and at 4-6 weeks after their quit date.•If the client requires additional support following the seven sessions, the advisor will arrange to make contact by telephone in two weeks to provide an additional follow up.

Approach: Flexibility in service model with a women centred approach.

•Face-to face assessment session, within 1 week of contact, in location of woman’s choice

•Women are offered intervention sessions at a location of their choice, each lasting around 30-60 minutes

•The number and frequency of treatment sessions will be according to the woman’ choice, including the option of support by text message or telephone.

•Women are CO monitored during face-to-face treatment sessions and at 4-6 weeks after their quit date

USUAL CARE INTERVENTIONRE

FERR

AL

TREA

TMEN

T

Data analysis

• Primary outcome measure = -% of treated smokers

•Secondary outcomes = -referrals, 4-week quits, CO validated quits, smoking status in 3rd trimester, birth outcomes

• Sample size = 146 pregnant smokers

Models for Access to Maternal Smoking cessation Support (MAMSS)

Reference:Bennett et al. Models for Access to Maternal Smoking cessation Support (MAMSS): a study protocol of a quasi experiment to increase the engagement of pregnant women who smoke in NHS Stop Smoking Services. BMC Public Health 2014, 14:1041http://www.biomedcentral.com/content/pdf/1471-2458-14-1041.pdf

Results:% referrals accepted (of those referred)

Models for Access to Maternal Smoking cessation Support (MAMSS)

Models for Access to Maternal Smoking cessation Support (MAMSS)

No. accepted

108 133

23 94

40 204

10 93

Models for Access to Maternal Smoking cessation Support (MAMSS)

No. treated smokers

28 93

8 42

9 87

6 49

Results:% treated smokers (of those referred)

Models for Access to Maternal Smoking cessation Support (MAMSS)

No. 4 week quit

9 29

1 18

4 40

2 14

Results:% 4 week quitters (of those referred)

Models for Access to Maternal Smoking cessation Support (MAMSS)

No. CO validated

227

1 7

2 33

2 12

Results:% CO validated quits (of those referred)

Qualitative evaluation methods

1. Documentary analysis of study management group minutes (09/2012 - 02/2014)

2. Semi-structured interviews• Referring midwives (n=9)• Treating clinicians (n=9)• Service Users (n=7)

• Framework analysis using NVivo 10

Models for Access to Maternal Smoking cessation Support (MAMSS)

Identification and referral

• Midwives trained to follow NICE opt-out pathway

• Carbon Monoxide testing problematic– Poor data

• Majority ‘agreed’ to being referred• Barriers to ‘agreement’ – most smokers

already intending to ‘cut down’• One area MAMSS clinician in clinic –

brief referral appointment

Models for Access to Maternal Smoking cessation Support (MAMSS)

Intervention delivery

• Challenging to make contact with women – use of mobile phone

• Majority of appointments in women’s homes• Treatment sessions were usually weekly for

around 6-12 weeks• Quit date set by 71% of those who had an

assessment session– Variation between sites (94% -56%)

• Informal contact between sessions• Some issues accessing NRT from pharmacy

Models for Access to Maternal Smoking cessation Support (MAMSS)

Data collection

• Specialist Quit Manager system developed• Delays – so local systems developed• MAMSS clinicians found the system

challenging; – inputting baseline questionnaires– Timely data entry (to meet Russell Standard)

• I-pads did not work in the community due to large areas without network coverage

• Significant amounts of data cleaning provided by Stop Smoking Wales

Models for Access to Maternal Smoking cessation Support (MAMSS)

Lessons for Practice• Need for greater control

– Referral and identification of pregnant women– Setting and recording quit dates– CO monitoring and recording

• Home visits and informal contact was well received

• Need for a better relationship with pharmacies

Models for Access to Maternal Smoking cessation Support (MAMSS)

ConclusionThe MAMSS project provides

evidence that women who smoke during pregnancy can be effectively supported to engage with stop smoking

services if a flexible, bespoke service is offered.

Models for Access to Maternal Smoking cessation Support (MAMSS)

Limitations of study

• Not a randomised controlled trial• Different data systems used across

the Health Boards – some still paper based

• CO monitoring and opt out referral not well established

Models for Access to Maternal Smoking cessation Support (MAMSS)

Acknowledgements• MAMSS National Steering Group:

Joanne Bass Julie BishopMererid Bowley Ceriann TunnahCatrin Ford Christian Heathcote-ElliottAngela Jones Sharn JonesSiobhan Jones Rachel LewisMargaret Munkley Carol OwenShantini Paranjothy Annie Petherick

• Hywel Jones (Cardiff University)• Marian Owoniyi (Cardiff University)• Dee Hickey (PHW Observatory)• Mieko Thomas, Luis Goncalves, Ray Henry (PHW Informatics)• Staff employed as specialist smoking cessation advisors for pregnant women • Health Board maternity teams• Community Pharmacies• Local Stop Smoking Wales teams• Pregnant women who were involved in MAMSS

Models for Access to Maternal Smoking cessation Support (MAMSS)