If Mothers Had Their Say: Research Informed Intervention Design for Empowering Mothers to Establish Smoke-Free Homes

Background & Purpose: Evidence indicates that the 60% of America’s children exposed to environmental tobacco smoke (ETS) exhibit significantly higher rates of health, learning, and behavioral problems, especially infants transitioning home from the neonatal intensive care unit (NICU). Two phases of a research-driven effort to integrate client perspectives into intervention design are reported for Project EMESH (Empowering Mothers to Establish Smoke-free Homes). Qualitative and quantitative study results were integrated to address elements for inclusion in a menu of options for mothers who are preparing to eliminate their babies’ ETS exposure. Methods: Phase I involved semi-structured interviews with the mothers of 20 NICU/alumni babies who regularly have contact with smokers (not necessarily the mothers). Interviews were thematically coded by two raters. Phase II involved secondary analysis of 75 randomly selected NICU/follow-up clinic patient records. The coding scheme identified population characteristics and staff recordings about ETS-related intervention. Results: The following themes emerged from mother’s responses about intervention options: (a) individualized support for their own quit attempts and harm reduction efforts; (b) help addressing other family members or caregivers who expose their babies to ETS; (c) a policy to enforce smoke-free environments; (d) home use awareness and enforcement tools; (e) help with professionally cleaning homes and cars of “third hand” smoke residue; (f) staff acknowledging the difficulty and complexity of mothers’ change efforts; (g) concrete rewards to reinforce change efforts; (h) housing and day care options free of  ETS; (i) the time to begin assessment and intervention should be “as early as possible” but individualized to “when mothers can handle it”; (j) positive aspects of group interventions exist but classes and groups are impractical with sick, vulnerable infants and geographical difficulties. Over 50% of mothers lacked self-efficacy for making the baby’s world smoke-free. Over 70% felt it would be helpful to include mentor-mothers in the intervention stream. Quantitative secondary data analyses indicated the infant age range when service providers have an opportunity to intervene is 3-59 months (mean=25 months). The average number of infant hospitalizations among 75 cases studied was 2.59, with total mean days hospitalized equaling133 (range 1-596 days); 64% were government insured. Almost half of the infants lived in communities with 16-30% maternal smoking rates. Chart review results also suggest that very few health care contacts with physicians, nurses, or social workers address babies’ possible ETS exposure; those that do tend only to address mothers’ smoking, not others in the child’s context; change-oriented discussions mostly emphasize education or awareness, and documentation is often in a commanding tone. Conclusions: ETS is costly in both human and health service system terms. These data inform the translational science processes of designing a menu-driven intervention for reducing babies’ ETS.  By making these stakeholders visible, EMESH phases next will include: (a) training providers to replace their ETS topic avoidance and blaming approaches with a motivational interviewing (MI) approach with mothers, (b) individualized, dynamic service menus to support mothers’ efforts at eliminating babies’ ETS, and (c) use of supported technology to promote peer and mentor-mother support opportunities.