1. Created by: Lindsey Koch, Carrie Smith, Jennifer Ames, Elizabeth Berkemeier, Catherine Buckel

2.  Total Population: 43,318  Race and Ethnicity: 93.5% white  High School Graduates: 89.4%  Jobless Rate: 9.3%  Median Income: $38,332  Persons Below Poverty: 22.9%  English as a Primary Language: 95.7% Source: US Census Bureau, 2008-2012 American Community Survey 5-year Estimates,

8.  Smoking during Pregnancy ◦ Mecosta County: 31.6% ◦ State of Michigan: 19.5%  Healthy People 2020 Goal: 1.4%  Potential Risks of Smoking during Pregnancy: ◦ Higher risk of miscarriage and pregnancy loss ◦ Prematurity and low birth weight in neonates ◦ Higher risk of SIDS ◦ Smoking will reduce breast milk supply ◦ Higher risks of allergies, asthma, and ear infections in infants

9.  Planned Parenthood  Catholic Charities of West Michigan  Mecosta County Health Department ◦ MI Child ◦ Healthy Kids ◦ Maternity Outpatient Medical Services ◦ Group 2 Pregnant Women ◦ Maternal Infant and Support Services  WIC  Mecosta County Community Team  Hope House Free Medical Clinic  Early Head Start (Mid Michigan Community Action Agency)  Early Success Right from the Start (MOISD school district)

10.  There appears to be adequate resources available in the community, but a lack of utilization. Evidence shows Mecosta County is almost double the state rate and 30x the Healthy People 2020 goal.  The ideal plan would be to engage physicians, community health nurses, health department employees, existing community organizations, healthcare students at Ferris State University, and the general public in addressing this issue.

11.  The “Keystone” of Community Health Nursing  Essential precursor to Community Health Intervention  Uses the community assessment to clearly describe and address the problem & etiology  Completes the Diagnostic process Muecke, M.A. (1984). Community health diagnosis in nursing. Public Health Nursing, 1(1), 23-25.

12.  Risk of pregnancy complications due to smoking during pregnancy among Mecosta County women related to: ◦ Lack of access to healthcare  Inadequate education on risks of smoking to fetus ◦ Poverty on the rise  Stressors at home may lead to difficulty quitting  As demonstrated in higher percentages of pregnant women who smoke (31.4%)  Infant mortality rate of 9.1  Low birth weight of 6.2%

13.  To reduce women smoking during pregnancy in Mecosta County to below the 2012 state average of 19.3%. ◦ Through more healthcare coverage/prenatal care for pregnant women ◦ More education by providers on dangers of smoking Use of Maternal Infant Health Program through Michigan Medicaid Provides transportation, education & support ◦ Reduce low birth weight percentages ◦ Reduce infant mortality Michigan Department of Community Health (2014). Pregnant women. Retrieved from: http://www.michigan.gov/mdch/0,4612,7-132-2943_4672-106183--,00.html

14.  Increased risk of placenta previa, preterm rupture of membranes, and preterm birth  Low birth weight  Cognitive deficits  Sudden Infant Death Syndrome (SIDS)

15.  Counseling  Pharmacological interventions such as nicotine replacement therapy  Psychosocial interventions, such as The Five A’s

16.  Ask, Advise, Assess, Assist, Arrange ◦ Determine if prenatal smoking is a risk ◦ Provide information about risks of prenatal smoking ◦ Interview to determine if smoking is an existing habit, how many cigarettes are smoked daily, how long the patient has been a smoker, etc. ◦ Provide tools to assist in smoking cessation ◦ Arrange for further counseling, prescriptions for nicotine replacement therapy, follow through with additional interventions if necessary

17.  Not all smoking during pregnancy can be eliminated through any intervention method  Comprehensive care initiated and continued in a prenatal care/clinical setting can increase the number of pregnant women who are able to quit smoking before delivery  Though not all smoking during pregnancy can be eliminated, education and intervention along with nicotine replacement therapy is the best option in assisting pregnant women to quit smoking  Ensuring continuous care and follow-through is important in having successful prenatal smoking cessation interventions

19. (1890-1947) “Father of Social Change Theories” Lewin’s change theory is a planned change’ guide that consists of three distinct and vital stages:  Unfreezing stage  Moving to a New Level or change stage  Refreezing Stage

20.  “The first stage involves finding a method of making it possible for people to let go of an old pattern that was counterproductive”.  “The second stage involves a process of change- in thoughts, feelings, behavior, or all three”.  “The third and final stage consists of establishing the change as a new habit or process”. This process is done by: Kaminski, J. (2011, March 23). Theory applied to informatics-Lewin's Change Theory. 6(1).

21. (ToC)  “Approach championed by realist methodologist…”  “Developed in U.S. in an effort to find ways of evaluating processes and outcomes in community- based programs…”  “A systematic and cumulative study of the links between activities, outcomes and contexts of the initiative” Douglas, F. C., Gray, D. A., & Van Teijlingen, E. R. (2010). Using a realist approach to evaluate smoking cessation interventions targeting pregnant women and young people. BioMed Health Services Research, 10(49), 1-7.

22. “ToC will link outcomes and activities and explain how and why the desired change is expected to come about” “…as a means of identifying and intervention’s inputs and activities and its intended outcomes” Douglas, F. C., Gray, D. A., & Van Teijlingen, E. R. (2010). Using a realist approach to evaluate smoking cessation interventions targeting pregnant women and young people. BioMed Health Services Research, 10(49), 1-7.

23. “Dr. Faye is a psychologist, marriage and family therapist and forensic evaluator. She is the founder and clinical director of the non-profit Parenting and Relationship Counseling Foundation (PaRC) in Granada Hills, California”. Snyder, F. (2012). The Causal Theory. Retrieved from Dr. Faye Snyder The Originator of The Causal Theory: http://www.drfayesnyder.com/the-causal-theory.html “Cause and Effect” She is the originator of The Causal Theory

24.  It includes: Attachment Theory  Lessons from Trauma Theory  Family Systems Theory  Some behavior and cognitive models, biopsychology and Zen Snyder, F. (2012). The Causal Theory. Retrieved from Dr. Faye Snyder The Originator of The Causal Theory: http://www.drfayesnyder.com/the-causal-theory.html

25. “The Theory is not just practical; it is supported by research” Causal theory is based on the concept that personality is created not born Ansari, R. M., Dixon, J. B., & Browning, S. A. (2013). Application of causal model to maternal smoking cessation intervention in pregnancy. Open Journal of Preventive Medicine, 3(4), 347- 354. Snyder, F. (2012). The Causal Theory. Retrieved from Dr. Faye Snyder The Originator of The Causal Theory: http://www.drfayesnyder.com/the-causal-theory.html

26. Borland, T., Babayan, A., Irfan, S., & Schwartz, R. (3013, May 14). Exploring the adequacy of smoking cessation support for pregnant and postpartum women. Retrieved from Bio Med Center Public Health: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3658958/  Absence of a county smoking cessation program can be a major barrier.  Emphasize, “…the importance of integrating tobacco-focused policy, practice and programming into reproductive and child health fields”.  “…policy that addresses smoking during pregnancy should be, “a pillar of any maternal and child health strategy.”  “…affordable Nicotine Replacement Therapy (NRT) …”; “…a necessity to establishing a comprehensive system…”

27.  Another barrier to cessation: “…easy access to cigarettes and exposure to other smokers and secondhand smoke…”  greater taxation of tobacco products  measures to reduce the availability of cheap cigarettes  further development of smoke-free policies  poverty reduction, housing and education support Borland, T., Babayan, A., Irfan, S., & Schwartz, R. (3013, May 14). Exploring the adequacy of smoking cessation support for pregnant and postpartum women. Retrieved from Bio Med Center Public Health: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3658958 /

28. What would be the eventual desired outcome? The desired outcome is to reduce women smoking during pregnancy by at least 30% in the next three years to put Mecosta County under the 2012 state average of 19.3%. HP2020=Healthy People 2020 targets Sources: Michigan Department of Community Health; US Census Bureau; County Health Rankings; MI Department of Technology, Management and Budget; Michigan League for Public Policy; Michigan Care Improvement Registry.

29. How long would you anticipate before you saw the changes? Once the plan is put into effect, we should see a slow decrease in the number of women smoking during pregnancy. This should be decreased the most at our goal time.

30. What interim outcomes might you track? We would track the statistics yearly of:  The number of pregnant women using the healthcare coverage for prenatal care  Number of pregnant women accepting education by providers on the dangers of smoking  Number of pregnant money using the Maternal Infant Health Program through Michigan Medicaid  Watching for a reduction in low birth weight percentages  Watching for a reduction in infant mortality  Checking to see if the number of tobacco products have decreased.

31. Are there already available measures that would help track any of the changes?  Yes, there is an ability to measure and track changes from year to year.  Available State and local statistics o Yearly o Bi-yearly

32.  Ansari, R. M., Dixon, J. B., & Browning, S. A. (2013). Application of causal model to maternal smoking cessation intervention in pregnancy. Open Journal of Preventive Medicine, 3(4), 347- 354.  Borland, T., Babayan, A., Irfan, S., & Schwartz, R. (3013, May 14). Exploring the adequacy of smoking cessation support for pregnant and postpartum women. Retrieved from Bio Med Center Public Health: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3658958/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3658958/  Current tobacco use and secondhand smoke exposure among women of reproductive age - 14 countries, 2008-2010. (2012). MMWR: Morbidity & Mortality Weekly Report, 61877-882.  District Health Department #10 (2014). Mecosta County health profile chartbook. Retrieved from http://www.dhd10.org/images/Mecosta_Chartbook_2013__Feb_18_2014.pdf  Douglas, F. C., Gray, D. A., & Van Teijlingen, E. R. (2010). Using a realist approach to evaluate smoking cessation interventions targeting pregnant women and young people. Bio Med Health Services Research, 10(49), 1-7.  Gilman, S. E., Breslau, J., & Subramanian, S. V. (2008). Social Factors, Psychopathology, and Maternal Smoking During Pregnancy. American Journal Of Public Health, 98(3), 448-453.  Kaminski, J. (2011, March 23). Theory applied to informatics-Lewin's Change Theory. 6(1).

33.  Kim, S. Y., England, L. J., & Kendrick, J. S. (2009). The Contribution of Clinic-Based Interventions to Reduce Prenatal Smoking Prevalence Among US Women. American Journal Of Public Health, 99(5), 893-898.  Leonard, T. (2001). Ten best reasons not to smoke while you’re pregnant [Brochure]. Santa Cruz, CA: Journeyworks Publishing  Mecosta Osceola Intermediate School District (2011). Resources for Mecosta & Osceola Counties. Retrieved from http://view.officeapps.live.com/op/view.aspx?src=http%3A%2F%2Fwww.moisd.org%2Fdownloa ds%2Fgenedfiles%2Fresources_for_mecosta_county_and_surrounding_area_20110928_194159_ 5.doc  Ricketts, S., Murray, E. K., & Schwalberg, R. (2005). Reducing Low Birthweight by Resolving Risks: Results from Colorado's Prenatal Plus Program. American Journal Of Public Health, 95(11), 1952-1957.  Snyder, F. (2012). The Causal Theory. Retrieved from Dr. Faye Snyder The Originator of The Causal Theory: http://www.drfayesnyder.com/the-causal-theory.html  Summaries for patients. Preventing tobacco use and related diseases in adults and pregnant women: U.S. Preventive Services Task Force reaffirmation recommendation statement. (2009). Annals of Internal Medicine, 150(8), I-46.