Evaluation of intensive programmes for pregnant women who smoke Anne Dowden, Director – Evaluation Research New Zealand September 2007

2Research New Zealand | September 2007 Prepared forOceania Tobacco Control Conference, 2007 Auckland Prepared byAnne Dowden, Research New Zealand In support Sue Taylor, T&T Consulting Jo Muschamp, Ministry of Health Contact DetailsAnne Dowden Research New Zealand Phone

3Research New Zealand | September 2007 Acknowledgements Sue Taylor and I would firstly like to acknowledge the Smokefree Pregnancy providers and their clients for their time, expert input and ongoing commitment to this important area. We would also like to acknowledge:  Jo Muschamp and her colleagues at the Ministry of Health who supported and funded this work  the team at Research New Zealand and T&T Consulting.

4Research New Zealand | September 2007 Background Evaluation Objectives Evaluation Activities Literature Review Sector analysis and coverage Standard of practice in New Zealand Best Practice guidelines Recommendations, lessons learnt Outline

5Research New Zealand | September 2007 Background Progress made in tobacco control over the past ten years - creation of smokefree environments. Progress on reducing the smoking rate for pregnant women and their families. 1999/2000 some 35+ providers funded to deliver services to pregnant smokers, 2005 a handful had a focus of delivering these intensive services. Evaluation to provide an evidence and knowledge base to guide future decisions for Smokefree Pregnancy services and interventions.

6Research New Zealand | September 2007 Evaluation Objectives Evidence base for effective Smokefree Pregnancy services. Gaps in coverage and opportunities for the smoking cessation services utilised by pregnant women. Promote information sharing and collaborative relationships. Describe and compare the different models of services. Identify key factors that promote or inhibit success. Identify the most effective mix of services (within financial constraints). Describe opportunities to re-orientate existing health services to better support pregnant women.

7Research New Zealand | September 2007 Evaluation Activities Multi-method evaluation (high stakeholder input, high workload) Including … Interviews with experts. International and NZ review of the literature. Sector analysis ‘Who’s doing what to support pregnant women?’ Develop practice guidelines - descriptions of current practice, good practice guidelines.  Workshops with successful providers.  Case studies of successful providers. Strategy and opportunities for the future.

8Research New Zealand | September 2007 Background Evaluation Objectives Evaluation Activities Literature Review Sector analysis and coverage Standard of practice in New Zealand Best Practice guidelines Recommendations, lessons learnt

9Research New Zealand | September 2007 Literature review promotes in-depth client focused approaches Specialist counselling services to supplement interventions delivered within routine care. Brief interventions delivered within routine antenatal care are unlikely to be effective on own. Lead maternity careers need guidelines on when specialist counselling is appropriate – need proactive referrals. In New Zealand evidence shows that the SmokeChange programme may be an effective intervention.

10Research New Zealand | September 2007 Literature review identified useful tools and noted limited evidence base Strategies to support behavioural interventions:  self-help tailored to pregnancy  use financial incentives and social-support with low-income and high risk pregnant smokers  biomarker feedback – useful tool. Harm reduction is a developing science:  debate on its use in smoking interventions in pregnancy. Literature: no evidence of long term postpartum effectiveness for successful pregnancy interventions.

11Research New Zealand | September 2007 Literature review showed need for system wide approaches System-wide delivery of smoking cessation interventions. Population-level interventions:  messages about health effects of smoking broaden understanding  women require strategies to help cessation attempts. Evidence-based smoking interventions targeting adolescent females and women in childbearing years:  contributes to reduction in numbers for pregnancy interventions.

12Research New Zealand | September 2007 Literature review promotes thoughtful design and evaluating interventions Designing interventions for smokers resistant to change:  self-help materials with advice or counselling  financial incentives  pregnant smokers and health providers can input into design  services targeting pregnant Mäori women and their whänau – kaupapa Mäori driven, acknowledge and facilitate whänau and community  role of partners and wider family/whänau  nicotine replacement treatment (NRT) used in conjunction with counselling – inform women of the risks. Interventions should be rigorously evaluated.

13Research New Zealand | September 2007 This literature review is available …

14Research New Zealand | September 2007 Background Evaluation Objectives Evaluation Activities Literature Review Sector analysis and coverage Standard of practice in New Zealand Best Practice guidelines Recommendations, lessons learnt

15Research New Zealand | September 2007 Sector analysis – who is doing what to support pregnant smokers in NZ? scan of collate information on organisations’ roles with:  pregnant women  in smoking cessation / reduction. Organisations’ contacted in two broad groups:  pregnancy support services (GPs, midwifery services etc)  smoking cessation services (DHBs, The Quit Group, Mäori health organisations etc).

16Research New Zealand | September 2007 Sector analysis - information sought The s requested information on:  work with pregnant women, and whänau  approach/role in working with clients about smoking  whether work on smoking with pregnant women and/or partners.

17Research New Zealand | September 2007 Coverage – few pregnant smokers are supported by a programme. Percentage supported by a programme/ year

18Research New Zealand | September 2007 Background Evaluation Objectives Evaluation Activities Literature Review Sector analysis and coverage Standard of practice in New Zealand Best Practice guidelines Recommendations, lessons learnt

19Research New Zealand | September 2007 Although there are significant needs, the standard of practice is high The programmes in NZ appear to have significant success.  Client referral systems.  Maintaining client relationships.  Achieving positive outcomes.  Impact/outcomes evaluations required to assess success. Skilled, yet dispersed workforce.  Due to isolation a ‘community of practice’ is yet to fully develop.

20Research New Zealand | September 2007 The standard of practice is high Wealth of knowledge.  A small number of individuals have world leading expert knowledge for working with pregnant smokers and partners/whänau. Delivery requires:  intensive training and support  ongoing commitment  support from a range of people in the sector.

21Research New Zealand | September 2007 Best practice guidelines New Zealand providers - display the following four common principles (these underpin the approaches required for Smokefree Pregnancy providers):  demonstrate a clear philosophy for the service - known and actioned by managers and staff  be credible - referral network, potential clients and clients  client centred - individually tailored intensive service, adapt to changing needs, appropriate for pregnancy  continuous quality improvement and reflective practices.

22Research New Zealand | September 2007 Best practice guidelines Organisational good practice means quality operations occurring in all areas.  Organisation/service philosophy.  Service delivery – intervention high quality, true to philosophy.  Marketing of service – linked to philosophy (leads to ‘credibility’).  Administration – robust processes, check-backs, success shared.  Human resources – training, reflective practice.

23Research New Zealand | September 2007 ‘Credibility’ Being credible is achieved in a number of different ways. Through having a midwife or nurse on staff. Publicise partnership with a medical expert and/or cultural experts.  P rovide expert advice and lend credibility. Through providing training services to referral networks  seen as ‘specialists’.

24Research New Zealand | September 2007 Background Evaluation Objectives Evaluation Activities Literature Review Sector analysis and coverage Standard of practice in New Zealand Best Practice guidelines Recommendations, lessons learnt

25Research New Zealand | September 2007 Recommendations Goal That all pregnancies are smokefree. Strategies All pregnant women who smoke, or have the potential to relapse to smoking during or soon after pregnancy, are identified and offered support.  Including pre-pregnancy and postpartum. All pregnant women, regardless of their readiness to make smokefree changes, are supported to maintain and protect any changes over the medium to long term including the postpartum period.  Including ‘spontaneous quitters’ – support to maintain change.

26Research New Zealand | September 2007 Recommendations A range of recommendations were presented to the Ministry and service providers.  Best practice principles.  Development of a strategic framework to support this sector. In future, with best practice principles will need to be in place for an impact evaluation of these important services.

27Research New Zealand | September 2007 Lessons learnt - evaluation process The literature review provided a significant evidence base and guided all aspects of the wider evaluation. High level of stakeholder involvement - important but time consuming. Time taken frustrating for Smokefree Pregnancy providers. It is important for all stakeholders to understand that while we now know and understand a lot, more evaluation work is required to collect robust evidence of the impact of these important services.

28Research New Zealand | September 2007 Utilisation of the evaluation findings Pregnant women are a priority population in the new tobacco control budget:  policy work on service development focusing on pregnancy and smoking  DHBs tobacco control plans being developed. Ministry is working closely with DHBs on plans seeking:  primary care activities (ABC and referral systems)  Smokefree Pregnancy interventions.

29Research New Zealand | September 2007 Summary Progress has been made in general and specialist Smokefree pregnancy services in New Zealand over the past ten years. Good practice is evident and can assist the further development of Smokefree Pregnancy services in New Zealand. The sustainability and plans for extending Smokefree/smoking cessation services and/or modifying the existing services needs careful consideration.  Service strengthening comes before expansion. Outcome/Impact evaluation important nest step.

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