1. Impact of reduced in-home secondhand smoke exposure on low birth weight prevalence and neonate health PEER Health Research Project Dr. Yayi Suryo Prabandari Dr. Erik Crankshaw

2. What is PEER Health?  US-funded program to support partnerships between researchers in countries like Indonesia with US researchers.  Goal:  To fill evidence gaps that will help to address important public health problems.

3. Presentation Map  Background  Research Question & Objectives  Study Approach and Method  Study Benefit  Expected Policy Impacts

4. Background

5.  Two out of three Indonesian men smoke.  Almost all people are exposed to secondhand smoke (SHS) in their homes.  SHS exposure among pregnant women is highly correlated with low birth weight (LBW).  LBW is a major cause of neonatal mortality and is associated with other neonatal health problems.  SHS exposure in homes can be reduced by a package of “smoke-free home” interventions.

6. Research Question & Objectives

7. Research Question Does reduced exposure to SHS among pregnant women result in a significant reduction in the prevalence of LBW and neonatal morbidity? Policy relevance – should active efforts to reduce in- home smoking be integrated as a funded, official public health intervention?

8. Study Objectives Show lower proportion of … 1. … LBW in intervention area 2. … neonatal morbidity in intervention area 3. … in-home smoking in the intervention area

9. Study Approach & Method

10. The study is innovative for Indonesia  First community-based smoking behavior modification research in Eastern Indonesia.  First use of a 3-level approach to reduce pregnant women’s exposure to in-home SHS.  First large-scale study of the relationship between pregnancy outcomes, neonatal health and SHS.

11. Quasi-experimental approach  Intervention and control communities.  Formative study prior to the intervention.  Subject identification and enrollment.  Four data collection waves in each enrolled household.

12. Three stage study intervention 1.Mass media campaign  Intervention area only, throughout study period  Focus on harm during pregnancy and early childhood  Focus on health benefits of smoke-free home 2.“Smoke-Free Home Community” education and declaration 3.Smoke-Free Home contracts – household level.

13. Enrollment Selection Algorithm

14. Final Target Households

15. Formative Data for Study Design  Community-level information for study design  Prenatal, antenatal, postnatal care providers & practices  Smoking behaviors, norms, & perceptions  Cooking practices (other environmental smoke sources)  Housing structures  Household communication & gender roles  Media mapping

16. Household data collection: 4 waves TopicBaseline 6 th pregnancy monthBirth 1 month post birth Socio-demographic Xupdate Update Smoking behavior, intensity XXXX Health care use, pregnancy care XXXX Cooking practices XXXX Secondhand smoke exposure XXXX Media practices, exposure XXXX Understanding SHS impacts XXXX Smoke-free contract compliance XXX Mother’s, neonate’s health X

17. Final Qualitative Data Collection  Assess intervention implementation  Barriers and challenges  Effectiveness, social acceptability  Impacts on social norms for smoking  Lessons learned for scale-up  Methods  Focus group discussions  In-depth interviews

18. Intended Policy Impacts

19. Community survey Qualitative methods for exploring community perception and opinion (in-depth interview, FGD ) Initial program Join in existing community meeting Women group (PKK) Men group Wife and husband (separate and couple) Youth Community leader Coordination meeting Community approach Agreement on establishing local regulation Issued a petition Local policy development Strategy for community: Implementation of Smoke Free House Kampong Quit Tobacco Indonesia works with Provincial & District Health Office Nichter, M., Nichter, M., Padmawati, RS., & Ng, N. Developing a smoke free household initiative: an Indonesian case study. Acta Obstetricia et Gynecologica. 2010; 89: 578–581

20. Improve support for community-led public health While health systems are being strengthened, communities can play an increased role in public health protection.  Promote tobacco education to all age groups  Changing social norms to reduce exposure to SHS  Improving neonatal health  Improving adult respiratory health; lowering cancer risks  Empowering people to encourage smokers to respect rights to a safer, smoke-free environment

21. Smoke-free home intervention as a low- cost way to improve neonatal health  Feasible and replicable at scale.  Lowers the prevalence of LBW.  Improves neonatal health and reduces need for illness-related health care.  A healthier neonatal period contributes to long- term gains in child growth and development.  Provides evidence of public demand for district health intervention