Now that's what I call blogging 2021

Posted by Mark Welford, Fuse Communications Manager, Teesside University

Let’s all channel British novelist E.M. Forster and play a little game of Only Connect. What connects the things below?

“Yes of course, they can all be a type of list” (said in the friendly yet ever so slightly patronising manner of host Victoria Coren Mitchell)

I think it's fair to say that we all love a list. I mean, the premise of another very popular BBC gameshow is basically to list pointless stuff.

So here again (a little later than advertised) is our annual list of the most-viewed Fuse blog posts of 2021!

You'd be forgiven for thinking that this would be dominated by Covid and the pandemic as we saw in the 2020 list.

Obviously, we had our fair share of pandemic related posts. Blogs about misinformation, food insecurity, malnutrition, obesity and what children made of it all. How it impacted on work and engagement with public partners, parents, decisionmakers, practitioners, policy-makers and commissioners. How it affected our mental health, our liberties and even inspired a song and a cat-scale of wellbeing!

But as you can see from the list below it didn't dominate the top 5 chart-toppers of 2021. Perhaps a little escapism goes along way...

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Katsushika Hokusai: The Great Wave off Kanagawa

5. The other third wave: a mass epidemic of very individual pain

Posted by Jack Nicholls, Lecturer in Social Work at Northumbria University

Lockdown restrictions were beginning to ease in the UK. But after the jubilation, what if you don't feel the way you think you should?

A very personal post by Jack Nicholls on the long-term mental health consequences of the pandemic, of lockdown and social restrictions, and of its easing. 

*Content/trigger warning: mental health, depression, suicidal feelings.

Page views: 938

Published: 16 April 2021.

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4. Patient and Public involvement with Parents during a Pandemic: the four ‘P’ challenge

Posted by Hannah Batten, Food and Human Nutrition undergraduate student at Newcastle University. Hannah was on a placement year with the Population Health Sciences Institute, as part of the MapMe study aiming to help parents assess child weight.

Body image scales on the MapMe website are being updated for MapMe2

"Most importantly, is to say to our participants that we are extremely grateful for their time and input, particularly during these uncertain times."

Hannah tells us how she and the MapMe study team met the challenges involved in recruiting and running an online Parent Involvement Panel (PIP) to help review documents and study materials, when parents were already dealing with a global pandemic. 

Page views: 1,029

Published: 5 March 2021.

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3. Should pregnancy 'be incentive enough' to quit smoking?

Posted by Susan Jones, Research Associate at Teesside University

In this blog post on #NoSmokingDay, Dr Jones explored deprivation, guilt, shame, stigma and the complex web of reasons behind smoking behaviour.

Just searched #smoking #pregnancy #incentives - struck by many tweets that say 'pregnancy should be incentive enough' to quit smoking. Clearly the stats tell a different story for a significant minority - the question surely is why and what can be done? @ASH_LDN @FreshSmokeFree

— Dr Susan Jones (@Susan_E_Jones) December 10, 2020

Page views: 1,155
Published: 10 March 2021.

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2. Things I wish I’d known when I started my PhD… (part 1)

Posted by members of the Population Health Interventions Programme at the MRC Epidemiology Unit

Research doesn't happen overnight, avoid comparison and channel your inner Arsène Wenger ("Le Professeur"). In our second most popular blog post, the early, mid and senior career researchers at University of Cambridge share their tips for PhD survival.

Here is part 2 which interestingly received only half as many views despite including a High School Musical reference.

Page views: 1,347

Published: 4 June 2021.

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1. Can Forest School inspire the next generation to be happy & healthy?

Posted by Katie Beresford, undergraduate student at Durham University

With more than 2,700 views this is our most read post of 2021 by some distance!

In it Katie explores growing up in the Lake District, embracing nature, finding school restrictive and struggling academically in her early years.

Nearly two decades later she is completing a Fuse summer internship with the NIHR School for Public Health Research and is tasked to review literature discussing the effectiveness of Forest School as a public health intervention.

Why not grab a coffee and take a walk with Katie into the woods to find out what she discovered...

Page views: 2,746

Published: 8 October 2021.

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So there you have it, the top five Fuse blog posts of 2021. Congratulations to Katie who wins a rare and coveted Fuse paperweight!  

Fantastically both Katie and Hannah's blog posts were part of our Fuse blog Student Series which we launched last year! This showcases posts by students who have been challenged to write a blog as part of their studies. The authors may be new to blogging and we hope to provide a 'safe space' for the students to explore their subject and find their voice in the world of public health research. Hopefully this will encourage other students to take the plunge!

As always, many thanks to our loyal readers and fantastic contributors.

Can we do any better in 2022? If you fancy giving it a go, please find out what we are looking for and how to take part here. All contributors receive a much sought-after Fuse badge.

Images:

2. Image: Katsushika Hokusai, (CC0 1.0), via Wikimedia Commons

4. Mr. Alexander Ottesen, CC BY-SA 2.5, via Wikimedia Commons

Is it ethical to promote quitting smoking to patients with mental health issues?

Posted by Susan Jones, Research Associate, Teesside University

Smoking rates and levels of dependency are high in people with psychiatric problems and, it has been argued, that smoking helps people with mental health disorders to cope with the struggles in their lives (Malone et al., 2018). On the other hand, the National Institute for Health and Care Excellence (NICE, 2013) argues that introducing a smokefree culture into NHS Trusts offers an opportunity for patients and staff to benefit in terms of physical and mental health and is achievable with appropriate support. Certainly this viewpoint was supported in our research:

"I think for some of our patients because it’s actually a learning disabilities hospital but obviously a lot of them have mental health issues as well, it increased their confidence and self-esteem. A lot of our patients had poor self-esteem and they actually achieved something by stopping smoking, they achieved something that was extremely difficult and I think it made them think, if we can do that we can do other things as well." 

Frontline Staff, Trust B

Nevertheless, by taking this position, NICE have highlighted a contentious issue. In our research we found that the patients and healthcare community were still divided about introducing smokefree policies and supporting patients and staff to quit smoking (Jones et al., 2020). There was a lot of passion on both sides! In some wards (mostly those with non-acute patients, such as those with learning difficulties or associated with forensics) staff and patients took on the challenge to change their environment and behaviours and embrace a smokefree way of life. They were creative in how they prepared for quitting and even made it fun, with games and decorations.

In other areas e.g. acute services, the challenges were different and there was much more scepticism about the ethics and value of offering support to quit smoking. Although awareness raising and training in smoking cessation was available, the role of choice and a pro-smoking narrative was widespread. 

Normalisation of smokefree policies

In mental health, smoking is an established cultural norm both in the community and in healthcare settings. We found that it is seen as an acceptable, even beneficial, coping mechanism for people who suffer from mental health disorders.

Research evidence would argue the converse; that the physical and mental benefits are far greater than continuing to smoke (Harker & Cheeseman, 2016). People with psychiatric problems tend to be highly addicted and there is a definite need to push through the initial stages of withdrawal from nicotine, which can be harder due to greater dependency, and more complicated due to interactions with psychiatric medication. Nevertheless, the evidence shows that people still want to be physically healthier, free from the downsides of addiction and supported to achieve these goals (Harker & Cheeseman, 2016).

Promoting normalisation through collective action

Perseverance is required to change any norm; old habits and perspectives die hard and continual reinforcement of new patterns are needed for success (Jones et al., 2020). This applies at an individual level but also at the organisational level.

Role of context

Our environment is so important in enabling or blocking behaviour; or even ‘nudging’ it in a certain direction (Ratschen et al, 2011). If a hospital is smokefree, then patients who don’t smoke will be able to maintain their status as non-smokers more easily. Alternatively, a smoking environment legitimises and encourages continued smoking. 

Sustainability

Maintaining changed behaviours, like smoking, is known to be challenging; however there is an inherent contradiction in implementing smokefree policies on-site only. Patients and staff move between hospital and community and it is all too easy for this to be seen as abstaining while in hospital, rather than quitting for good.

What we found 

Two mental health trusts in North East England - Northumberland Tyne and Wear NHS Foundation Trust and Tees, Esk and Wear Valleys NHS Foundation Trust - went smokefree in March 2016. In our research to evaluate the implementation of smokefree policies within the trusts, we found that:

• Inroads had been made in changing an entrenched, smoking culture into one that was smokefree on Trust sites. However, there remained variations across specialities and challenges to full implementation.
• Once there was sufficient ‘buy-in’ to a non-smoking culture it was anticipated that the issues relating to enforcement and perceived risk would diminish.
• Long-term perseverance is required to establish smokefree sites in participating mental health trusts, supported by robust, routine, data collection.
• Normalisation Process Theory and logic modelling are helpful in increasing understanding of the dynamic implementation process. 

Policy relevance and implications

• Careful use of language is needed to encourage smokefree policies to be seen positively.
• When interpretation of the term ‘patient leave’ was left open for leave to be used for smoking, it led to inconsistent practice.
• Consistency of enforcement is key to success.
• There were many details that needed to be worked out following the introduction of the policies; suggesting a requirement for ongoing review and response in a timely manner.

Read more about Sue's research in this Fuse research brief: Introducing smokefree policies into hospital mental health services.

References:

Harker K, Cheeseman H. The mental health and smoking action report: the

stolen years. 2016 [Available from: https://ash.org.uk/information-and-resources/reports-submissions/reports/the-stolen-years] 

Jones, Susan E; Billett, A; Mulrine, S; Clements, H; Hamilton S. (2020) Supporting mental health service users to stop smoking: findings from a mixed method evaluation of the implementation of nicotine management policies into two mental health trusts. BMC Public Health, 20:1619

https://doi.org/10.1186/s12889-020-09673-7

Malone V, Harrison R, Daker-White G. Mental health service user and staff

perspectives on tobacco addiction and smoking cessation: a meta-synthesis

of published qualitative studies. J Psychiatr Ment Hlt. 2018;25(4):270–82. https://doi.org/10.1111/jpm.12458

National Institute for Health and Care Excellence. Public health guidance 48:

smoking: acute, maternity and mental health services. London: NICE; 2013. https://www.nice.org.uk/guidance/ph48

Ratschen E, Britton J, McNeill A. The smoking culture in psychiatry: time for

change. Brit J Psychiat. 2011;198(1):6–7. https://doi.org/10.1192/bjp.bp.110.081372

Images:

1. “Smoke-Free Bench” by Michael Coghlan via Flickr.com, copyright © 2011: https://www.flickr.com/photos/mikecogh/5645977385/in/photostream/ (CC BY-SA 2.0)

2. Copyright © South Tees Hospitals NHS Foundation Trust: https://www.southtees.nhs.uk/news/services/trust-to-go-completely-smokefree/ (2019)

The views expressed here are those of the authors and do not necessarily reflect those of the author's employer or organisation.

Should pregnancy 'be incentive enough' to quit smoking?

Guest post by Susan Jones, Research Associate, Teesside University

I have seen many people on twitter express the view that thinking about their baby should make pregnant women automatically quit smoking. Indeed many women when they decide to try for a baby or find out they are pregnant do quit smoking. However, it does seem illogical - and shocking - to many that this is not always the case.

 

Just searched #smoking #pregnancy #incentives - struck by many tweets that say 'pregnancy should be incentive enough' to quit smoking. Clearly the stats tell a different story for a significant minority - the question surely is why and what can be done? @ASH_LDN @FreshSmokeFree

— Dr Susan Jones (@Susan_E_Jones) December 10, 2020

For those who do continue to smoke, it is perhaps more of a hint of a complex web of reasons behind their smoking behaviour, rather than any greater willingness to harm their baby. Smoking throughout pregnancy is often associated with environmental and social deprivation, which gives us a clue. Hilary Graham’s seminal work into women’s smoking and its association with family health, published in 1987, opened the door to a new understanding of what some of the reasons might be for this apparently illogical and paradoxical behaviour on the part of pregnant women from deprived communities. Graham concluded that:

"The study suggests that, for a significant minority of mothers, poverty and caring combine with low levels of physical and emotional energy, with sleep problems and with feelings of social isolation. In this context, smoking appeared to provide a way of coping with caring-in-poverty: a way of coping alone with the demands of full-time caring and with the struggle of making ends meet."

This work revealed that there were other, stronger reasons to continue smoking, which counteracted any impulse to quit.

Guilt and shame

An earlier study of ours heard pregnant smokers confess to feeling guilty and ashamed of smoking in pregnancy and how they are very aware of the stigma associated with their behaviour:

“But then once I lit it up and had half of it I felt guilty. But it took that edge away, but I still felt guilty. So if I felt even more guilty I probably mebbees wouldn’t have touched it, but I feel weak because I have had to do it.”

“I think the kids always make it like, they have more effect on you than what anyone else does, because they're, well you feel guilty if you're letting them down and doing something they don't want you to do.”

We also found that sometimes it can be a distrust of public health messages combined with a real lack of knowledge about the mechanics of how smoking affects the developing baby. Nevertheless, it must be acknowledged that, for whatever reason, not everyone says they want to quit; but of those who do want to quit, some say they do not feel able to. For the sceptics out there, this may seem only subtly different to choosing to smoke, alternatively it may be a real barrier to quitting. Graham’s work would suggest the latter. More recent research has built on her findings and investigated what methods of support may work for these pregnant women, who do not quit, and for whom the health outcomes are comparatively worse for themselves and their babies.

What can be done?

Research over several decades has shown that there are ways to support pregnant women to quit smoking, focusing on:

• Referring to stop smoking support services
• Offering support to change behaviour
• Support through medication.

It is clear now that opt-out approaches to referral and carbon monoxide monitoring and much more personalised support are also helpful to women (see our short video below).

   

Work has been undertaken to implement these supports more fully; e.g. the Local Maternity Systems (LMS) in North East England designed the Maternity Pathway and have led the work across the organisational systems to integrate these mechanisms. Becca Scott, the North East Local Maternity Systems Public Health Prevention Lead says:

"The LMS have led North East organisations and service users to contribute to the target of 5% or less women smoking in pregnancy by 2025. That would mean 2723 fewer women smoking at time of delivery across the North East since 2018. It does this by offering all expectant mothers, and their partners, a multiagency-developed, smoke-free pregnancy pathway and minimum service standards (as detailed in each of the Maternity providers bespoke plans). The impact of the engagement with the work has seen prioritisation throughout all Local Authority Health and Wellbeing boards, as well as consistency in the way smoking in pregnancy is identified and supported, which is demonstrated in significant improvement in adherence to NICE Guidance."

What more can be done?

The results of this partnership work are encouraging. Is there anything else that can be done? The evidence for the effectiveness and cost-effectiveness of financial incentives to support pregnant women to quit has been building. Trials have been conducted which have found that there is "substantial evidence for the efficacy of incentives for smoking cessation in pregnancy" – however this idea has encountered significant public scepticism and opposition.

ash. Smoking in Pregnancy Challenge Group Webinar - Incentive schemes

Although there has been more balanced reporting too and more recently, the headline below suggests the idea has become more acceptable.

Capture from The Sun online (09/03/21)

Modelling financial incentives in smoking in pregnancy

A team of us (details below*) have been awarded funding from the NIHR Applied Research Collaboration (ARC) North East & North Cumbria Open Funding Competition to look into an alternative way to take into account the views and responses from all stakeholders, including staff, pregnant women, and the public. We will also be building a mathematical model based on Evolutionary Game Theory (EGT). EGT is a mathematical framework of contests, strategies and analytics into which Darwinian evolution can be modelled. It is designed to capture the strategic interactions between stakeholders, because ultimately these interactions will drive health behaviour. Incentivisation will be modelled to see how it affects some behaviours and in what contexts. We hope the model will be able to guide commissioning and provision, so that any intervention is as effective and cost-effective as possible, without having to conduct further lengthy and expensive trials beforehand. Watch this space!

*Associate Professor Emma Giles (Teesside University), Professor Falko Sniehotta (Newcastle University and University of Twente), Dr Jean Adams (University of Cambridge) and other partners working in NHS Trusts and local authorities. Colleagues in the School of Computing, Design and Digital Technologies, Associate Professor The Anh Han and Tedy Cimpeanu from Teesside University.

Now that's what I call blogging 2019

Posted by Mark Welford, Fuse Communications Officer, Teesside University

Happy New Year – can I still say that or have we reached peak-greet when this obligatory salutation is no longer required in email, phone, or awkward fleeting corridor exchange?

This time of year is all about numbers: the 12 days of Christmas, the pounds you’ve gained (lbs) or lost (£), counting steps, units, the 31 days of Dry January, Veganuary, or the point at which you can grant yourself a run free day.

It therefore seems fitting that the Fuse blog has a countdown of its own.  Last year was a fine vintage for blog posts but you may not have had the opportunity to read all 40 of them.  To save you time we have had a look back and created a Top 5 Chart of the ‘bestsellers’.

So without further ado, here’s our chart toppers:

5. The provocatively titled Can cancer ever be a good thing? in which Fiona Menger (@slt_fi) revisits the writing of 'cancer columnist' John Diamond while working on a head-and-neck cancer research study with a focus on a phenomenon called post-traumatic growth.

Page views: 585.  Posted: 31 May 2019 

4. In What old crisp packets dig up Duika Burges Watson (@debedub) gets hands on to unpack the mystery of the humble crisp.  What is their continued value as ‘food’ and can we still enjoy them as a cultural icon without creating so much waste and damaging our health?

Page views: 640.  Posted: 22 February 2019

Still from the animation

3. Why do some women continue to smoke when they are pregnant?  Sue Jones (@Susan_E_Jones) shares research findings on overcoming barriers to implementing NICE guidance on supporting pregnant women to quit smoking.  The blog includes a short animation which was developed based on the findings.

Page views: 663.  Posted: 10 May 2019

2. If at first you don’t succeed, try, try, try & try again...  Suzanne Moffatt (@SuzanneMoffatt) reflects on 58 months of knock backs in her efforts to secure ‘the big grant’ because multiple failures before success is often untold and sometimes persistence pays off.

Page views: 686.  Posted: 15 February 2019

Courtesy of Children's Future Food Inquiry via twitter

1. "It’s time to act!  It’s time this country gave every child the right to food!"  Pamela Graham (@PamLGraham) begins her blog post with this powerful statement from Corey (pictured right), a 15-year-old Young Food Ambassador who sat on a stage in Westminster and bravely told an audience about her experiences of food insecurity.  With more than double the views of its nearest competitor, Young people taking a stand for their #Right2Food takes the crown as most popular blog post in 2019.

Page views: 1474.  Posted: 03 May 2019

So there you have it, the top five Fuse blog posts from 2019. Can we can do any better in 2020? If you fancy giving it a go, please find out what we are looking for and how to take part here.

P.s. perhaps we need to look more closely at what's going on in February and May!?


Image:

1.  'Now That's What I Call Music! 1989' by brett jordan via Flickr. Attribution 2.0 Generic (CC BY 2.0): https://www.flickr.com/photos/x1brett/45056607035/

Perseverance and Public Health: creating a cultural shift takes time

Guest post by Susan Jones, Research Associate, Teesside University

I spoke to a young woman the other day who had moved to North East England recently. She already had a little boy, just coming up 2 years old, and was now well on in her next pregnancy. Because I had been involved in evaluating babyClear© - an intervention to help support expectant mothers to stop smoking - I asked her whether the midwives had enquired if she smoked, (she doesn’t). “Oh yes”, she said, “they’re much more into keeping a close eye on you here”, as compared with the region where she lived before.

This buy-in by maternity staff, and the change to practice, is reflected in our paper, recently published in BMC Health Services Research (Jones et al., 2019)[1], in those Trusts that facilitated the intervention most successfully.

It is crucial, yet difficult, to answer questions about the effectiveness of initiatives like these. It takes time and perseverance t
o identify the questions, conduct the research and bring in the system and practice changes, which in turn support behaviour change in patients.

How do we go about answering questions about effectiveness of interventions designed to support people to change their behaviour and to become healthier?

It was in 2012, that the findings from interviews with midwives were first published (Beenstock et al., 2012)[2] and the search for new ways of embedding National Institute for Health and Clinical Excellence (NICE) Public Health Guidance 26 (2010)[3] more thoroughly, began. As a result, babyClear© was initially implemented across North East England from 2013 to 2015.

Fundamentally, interventions like babyClear© can be shown to be effective in certain circumstances (NICE, 2010; Bell et al., 2018)[4] but our latest paper found that these changes required specific contexts and cultures in the implementing organisation to maximise their effectiveness and potentially their sustainability and transferability.

These changes in staff practice and patient behaviour do not happen in isolation; the external context is important too and, in this case, the national context has become increasingly supportive.

For example, there have been a number of new pieces of legislation, guidance and reports during this time, all pushing in the same direction:

• Saving babies’ lives: reducing stillbirth and neonatal death: a care bundle (NHS England, O'Connor and Gould, 2014)[5]
• Tobacco Control Plan: Delivery Plan 2017 - 2022 (Department of Health and Social Care, 2018)[6]
• Hiding in Plain Sight; treating tobacco dependency in the NHS (Royal College of Physicians and Tobacco Advisory Group, 2018)[7]
• Not to mention ongoing lobbying from the Challenge Group (2018)[8], a coalition of likeminded, stop smoking, activist organisations, with their ‘Review of the Challenge’.

Clearly, there is an appetite to find solutions to the health problems that smoking causes; however, imposing regulation, without understanding and dealing with the causes, is never going to be hugely effective in a democracy like ours.

So what we see is a lot of different ‘scatter gun’ approaches all dedicated to the same aim – typical of lots of health and social interventions – but is this the best approach?

It is being recognised more and more that intervening in complex systems, such as the NHS, is both necessary and – at the same time – problematic. Largely, the problems come from a lack of understanding of the multiple complexities of the contexts and the effect of cultures upon outcomes. New ways of combining research methods are required to investigate these complex systems and find appropriate answers (Moore et al., 2014)[9]. Updated guidance from the Medical Research Council on evaluating complex interventions is being drafted as I write.

Fuse Complex Systems research programme

Only when the links – or active ingredients – between the different elements of an intervention are identified, and proper attention is given to the contexts and cultures surrounding it, will we be able to understand the necessary environment and resources for it to thrive, ensure its sustainability and maximise outcomes.

Our paper is one step in this direction but there is much more to do. Fuse has a Complex Systems research programme, because the researchers know how important it is. They will soon be publishing their plans for the future direction of their research on this topic.

This is an area where research and evaluation are moving fast, as they attempt to get to grips with the way health and public health are changing in the lives of staff and patients.

References: 

1. Jones, S. et al. (2019) What helped and hindered implementation of an intervention package to reduce smoking in pregnancy: process evaluation guided by normalization process theory. BMC Health Services Research. Available at: https://rdcu.be/bA4fK (Accessed: 20th May 2019).
2. Beenstock, J. et al. (2012) 'What helps and hinders midwives in engaging with pregnant women about stopping smoking? A cross-sectional survey of perceived implementation difficulties among midwives in the North East of England', Implementation Science, 7(1), p 1. 
3. National Institute for Health and Care Excellence (2010) Public health guidance 26: Quitting smoking in pregnancy and following childbirth. London: NICE. 
4. Bell, R. et al. (2018) Evaluation of a complex healthcare intervention to increase smoking cessation in pregnant women: interrupted time series analysis with economic evaluation. Tobacco Control. Available at: http://tobaccocontrol.bmj.com/content/early/2017/02/10/tobaccocontrol-2016-053476 (Accessed: 20th May 2019). 
5. NHS England, O'Connor, D. and Gould, D. (2014) Saving Babies Lives: reducing stillbirth and neonatal death: a care bundle. Available at: https://www.england.nhs.uk/wp-content/uploads/2016/03/saving-babies-lives-car-bundl.pdf (Accessed: 10th April 2019). 
6. Department of Health and Social Care (2018) Tobacco Control Plan: Delivery Plan 2017 - 2022. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/714365/tobacco-control-delivery-plan-2017-to-2022.pdf (Accessed: 20th May 2019). 
7. Royal College of Physicians and Tobacco Advisory Group (2018) Hiding in plain sight: Treating tobacco dependency in the NHS. Available at: https://www.rcplondon.ac.uk/projects/outputs/hiding-plain-sight-treating-tobacco-dependency-nhs (Accessed: 11th April 2019). 
8. Challenge Group (2018) Review of the challenge 2018. Available at: http://ash.org.uk/information-and-resources/reports-submissions/reports/smoking-in-pregnancy-challenge-group-review-of-the-challenge-2018/ (Accessed: 10th April 2019). 
9. Moore, G. et al. (2014) Process evaluation of complex interventions: UK Medical Research Council. Available at: https://mrc.ukri.org/documents/pdf/mrc-phsrn-process-evaluation-guidance-final/ (Accessed: 10th April 2019).

Image:

1. 'Smoking when pregnant' by johndavison883 via Flickr. Public Domain Mark 1.0.

Why do some women continue to smoke when they are pregnant?

Guest post by Susan Jones, Research Associate, Teesside University

"I was 12 years old when I started to smoke. I wasn’t thinking long-term, about my future, about the adult world I would one day join … I just wanted to look cool among my peers, be accepted and act grown up. Then I really did grow up and I was still smoking. Then I became pregnant … and I was still smoking. I didn’t exactly choose to be a smoker when I was pregnant but here I am ... addicted and not really wanting to give it up, or even if I wanted to, I don’t think I could – even for my baby.

"My mam smoked when she was pregnant with me, and I’ve turned out all right; all my family smokes, all my friends smoke, my partner smokes too; in fact smoking is a part of all my close relationships, especially with my partner, we smoke together, it is part of how our relationship works."

"I feel guilty, oh so guilty, but I can’t, I really can’t give up – I simply do not have the confidence to do it. I know that ‘smoking is bad for my baby’; I care for my baby and don’t want to do anything that would cause harm, and I’m really looking after myself, eating well, not drinking any more. I’ve cut down but I hardly dare think about quitting smoking, how on earth would I cope? And my partner, he’s not willing to change his smoking habits, or at least he’s agreed he’ll just not breathe over me when he’s been smoking, but he’s not even prepared to cut down – all he does is tell me, you must quit for the sake of the baby." 

A composite from interviews with pregnant smokers and maternity staff.

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Smoking is highly addictive and habit forming; many people enjoy the feeling it brings too[1]. Nevertheless the damage from smoking to the developing baby is well documented and the high level of smoking in pregnancy is still a major public health concern[2]. The National Institute for Health and Care Excellence (NICE) Public Health Guidance 26 (2010)[3] sets out all the trial-based evidence relating to the activities health professionals should take to support pregnant women to quit smoking. BabyClear© is a programme that supports health professionals to implement NICE guidance and provides standard training for them in order to carry out the activities in the most effective ways[4].

When we evaluated the implementation of the babyClear© package during its roll-out across North East England, we found that, for healthcare practitioners to challenge smoking behaviour amongst pregnant women, there needs to be a whole support system in place for both the professionals and the women whose behaviour they seek to change[5].

We recently developed an animation, based on our findings, which you can watch here:

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South Tees Hospitals NHS Foundation Trust took part in the evaluation of the implementation of the babyClear© package and works closely with its local stop smoking service. As Joanna Feeney, the Smokefree NHS Strategic Manager, says:

"South Tees is a great example of how Stop Smoking Services and Maternity Services can work together to help support Pregnant women to have Smokefree Pregnancies. 

"Most women who smoke during their pregnancy may know that smoking is bad but they are not aware of all the risks to them or to baby, they are also not aware of the help and support that is available to quit, including treatments such as Nicotine Replacement Therapy. 

"Implementing advice and treatment as part of routine Maternal care that is continued outside of hospital with the Stop Smoking Service helps ensure that babies are given the best start in life. 

"Last year in South Tees there were 334 more babies born Smokefree compared to 2012, and this year following the great work done on the wards at James Cook University Hospital the numbers are continuing to reduce but we recognise that there is still more to be done to ensure that every baby is born smokefree."

The Maternity and Stop Smoking Services reviewed the referral pathway and developed an online referral system that not only makes it easier for midwives but increases the speed with which women are contacted and given an appointment with the Stop Smoking Service.

Image courtesy of South Tees Hospitals NHS Foundation Trust

The Stop Smoking Service provides regular feedback to Maternity on the outcomes of women referred, enabling Maternity to offer bespoke interventions to those women who do not engage with treatment.

A further example of how South Tees Hospitals NHS Foundation Trust has moved towards a whole support system and worked in close partnership with stop smoking services is an initiative they undertook last year to redecorate the entrance to their maternity unit using eye-catching posters with a strong, stop smoking message.

And now, a year on, Kay Branch, Consultant Public Health midwife, South Tees Hospitals NHS Foundation Trust says:

"We are still really proud to have led the way towards a smokefree Trust. Our staff have noticed a reduction in the presence of anyone smoking outside entrances. 

"We continue to work collaboratively with the local stop smoking service to ensure a streamlined service for women and their partners. Nicotine replacement therapy is available to all of our patients and is widely used across maternity. 

"Our smoking at time of delivery reflects our hard work and passion for smokefree families."

Maternity’s lead has inspired the whole Trust to implement a systematic approach to treating tobacco dependency with Maternity being the model ward.

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I would encourage you to take a look at the animation above and publications relating to the roll-out of the babyClear© intervention package across the North East region. Please do share them with commissioners and providers of services, but also your colleagues, family and friends and any pregnant smokers you know.

More information on our evaluation work can be found here on the Fuse website.

References:

1. Chamberlain, C., O'Mara-Eves, A., Porter, J., Coleman, T., Perlen, S. M. et al. (2017) Psychosocial interventions for supporting women to stop smoking in pregnancy. Cochrane Database of Systematic Reviews. Accessed on 18/03/19 at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001055.pub5/epdf/full
2. Bauld, L., Graham, H., Sinclair, L., Flemming, K., Naughton, F. et al. (2017) Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study. Health Technology Assessment, 21(36). https://www.journalslibrary.nihr.ac.uk/hta/hta21360#/abstract
3. National Institute for Health and Care Excellence (2010) Quitting smoking in pregnancy and following childbirth: public health guidance 26. NICE: London https://www.nice.org.uk/guidance/ph26/resources/smoking-stopping-in-pregnancy-and-after-childbirth-pdf-1996240366789
4. Bell, R., Glinianaia, S. V., Van der Waal, Z., Close, A., Moloney, E., Jones, S., Araujo-Soares, V., Hamilton, S., Milne, E., Shucksmith, J., Vale, L., Willmore, M., White, M., Rushton, S. (2018) Evaluation of a complex healthcare intervention to increase smoking cessation in pregnant women: interrupted time series analysis with economic evaluation. Tobacco Control, 27: 1. Accessed on 18/03/19 at: http://tobaccocontrol.bmj.com/cgi/content/full/tobaccocontrol-2016-053476
5. Jones, S.E., Hamilton, S., Bell, R. Araújo-Soares, V., Glinianaia, S.V., Milne, E.M.G., White, M., Willmore, M., Shucksmith, J. What helped and hindered implementation of an enhanced package of measures to reduce smoking in pregnancy: process evaluation guided by Normalization Process Theory. BMC Health Services Research [In press]

The challenges (and joys) of evaluating babyClear©: a package of support to help pregnant women to stop smoking

Guest post by Sue Jones, Research Associate, Teesside University

A team of Fuse researchers from Newcastle and Teesside Universities published findings from the babyClear© study a few weeks ago and I thought that I’d put finger to keyboard to share with you the challenges and joys of evaluating the roll out of this innovative intervention.

In 2012, I became involved with evaluating babyClear©, a package of support for maternity and stop smoking services, designed to help them to deliver the stop smoking message more effectively to pregnant women. BabyClear© was due to be rolled out regionally across North East England and evaluated throughout, which presented a number of challenges:

• Challenge 1: different research questions – we wanted to know if this new approach worked and would it help women quit but we knew that this would not be enough; we wanted to understand what influenced those figures, and what healthcare staff need to do to be most effective.
• Challenge 2: ethical dilemma – ethically we could not deny pregnant women a test like carbon monoxide monitoring that was known to improve outcomes to some degree, so the regional rollout of babyClear© offered a prime opportunity to evaluate the intervention using a natural experiment1.
• Challenge 3: wide variety of stop smoking delivery models – the extent of austerity measures experienced by the public sector has been far greater than anticipated when the research was envisaged in 2011. At the same time responsibility for delivery of stop smoking services has been moved to local authorities who themselves are under extreme pressure to reduce spending. This has created a wide variety of stop smoking delivery models, all trying to provide a low cost service but with implications for the implementation. For example: babyClear© was designed to be a package that could easily slot into existing services, however it assumed a number of systems were standard when they were not, such as a midwife available at dating scan appointments and a local stop smoking specialist in pregnancy. All those Heinz 57 varieties of stop smoking service delivery models and systems within maternity services, each one different from every other, made it logistically challenging to implement the new pathway, leading to delays of varying lengths in each Trust area.
• Challenge 4: researching within a changing system – due to ongoing changes largely in the delivery of stop smoking services, but also in maternity, and their impact on the implementation of babyClear©, data collection plans had to be re-thought again ... and again ... and again to reflect what was happening out in the real world! 

We were greatly helped in approaching some of these challenges by the publication in 2014 of the Medical Research Council (MRC) Guidance on process evaluation of complex interventions. Using this guidance, we were able to start re-shaping our thinking in terms of how the qualitative data could be used synergistically with the numerical data. We set about strengthening the methodology with a retrospective logic model, weaving contextual data into the mix and with an eye on the mechanisms of impact.

After overcoming these challenges, along came the joys: the findings of our study proved that babyClear© was not only effective but also cost-effective, which was a great achievement in such a short timescale. This new approach, which supported midwives to offer universal carbon monoxide screening and refer pregnant smokers quickly to expert help, nearly doubled quit rates.

The findings highlighted that we could systematically help women to stop smoking in pregnancy which will result in already well-evidenced outcomes such as:

• Help mothers have babies who are heavier and healthier than if they continued smoking
• Help more mothers lead healthier lives
• Help mothers live longer and see their children grow up
• Help the children to live and run and grow up surrounded by smoke free air; and 
• Enable them to not be held back by smoking-related poor health

So have a read of our paper, this has the nitty-gritty of the statistical outcomes.

Importantly, soon we hope to be publishing the details about the how, what, when, where, why questions that were the focus of the qualitative process evaluation. Without this it is difficult to know how to implement it elsewhere to best effect and why it works well in one place and not another.

Celebrate our findings with us; if the maternity and stop smoking services are able to use the babyClear© approach to implement best practice/national guidance it can offer the support that is needed so that more women stop smoking during their pregnancy than did before. So keep your eyes peeled for my next blog – which will focus on the findings from the process evaluation.


Reference:

1. “A natural experiment is an empirical study in which individuals (or clusters of individuals) exposed to the experimental and control conditions are determined by nature or by other factors outside the control of the investigators, yet the process governing the exposures arguably resembles random assignment”. (Reference: en.wikipedia.org/wiki/natural_experiment)     More info: Craig P, Cooper C, Gunnell D, Haw S, Lawson K, Macintyre S, Ogilvie D, Petticrew M, Reeves B, Sutton M, Thompson S. Using natural experiments to evaluate population health interventions: new Medical Research Council guidance. J epidemiol commun h. 2012 May 10:jech-2011.

Related content:

• News story: Scheme’s success at stopping mums-to-be smoking
• Video courtesy of Fresh - Smoke Free North East, the region’s dedicated tobacco control office