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Reducing Tobacco Use Among Pregnant WIC Clients by Increasing Enrollment in Tobacco Cessation Programs
Summary
Impact Statement:
A local health department increased early enrollment of pregnant women in smoking cessation programs to reduce risks of pregnancy complications, premature delivery, and their infants being low-birth weight, stillborn, or dying from SIDS.
Summary:
Women who smoke during pregnancy are at increased risk of pregnancy complications and premature delivery, and their infants are at risk of low birth weight, stillbirth, or sudden infant death syndrome (SIDS). Comparable with national data, 10.7% of women smoke at “any time during pregnancy” within the Central District Health Department (CDHD) service area (Idaho Vital Statistics 2011, Idaho Department of Health and Welfare, Division of Public Health, Bureau of Vital Records and Health Statistics, February 2013). Women, Infants, and Children (WIC) clients are at higher risk of smoking because of their low socioeconomic status and lower education levels. CDHD current smoking cessation control efforts targeting pregnant WIC clients who smoke enroll only half of reported WIC tobacco users in the smoking cessation program. However, once enrolled, more than half quit or reduced tobacco use. CDHD conducted a quality improvement (QI) process to reach more pregnant women by enrolling them in the smoking cessation program.
Using the Plan, Do, Study, Act (PDSA) improvement model, CDHD analyzed the current enrollment approach and worked to improve it. To learn about the current process, CDHD conducted focus groups with pregnant WIC clients who use tobacco and involved WIC staff in brainstorming and completing a process flowchart and a fishbone cause-and-effect diagram. This work provided information about barriers and solutions to enrollment and participation in the program. After reviewing all data, WIC staff identified three top solutions, and the QI team selected reducing paperwork and streamlining the referral process as the most feasible solutions to pilot. Three enrollment documents were merged into one, and staff added a fax referral to the Idaho QuitLine as a resource. Solutions were tested, and results showed that WIC staff required additional training on promoting client enrollment in the modified process (training was provided). By the end of the project, staff knowledge improved. Clients received enhanced tobacco cessation services through referral to QuitLine. Staff plan to expand the improved enrollment process and QuitLine fax referral to all WIC clinics within the CDHD area.
Organization that conducted the QI initiative:
CDHD
Citation:
Graff, J. Public Health Quality Improvement Exchange. Reducing Tobacco Use Among Pregnant WIC Clients by Increasing Enrollment in Tobacco Cessation Programs. Tue, 03/04/2014 - 10:30. Available at http://www.phqix.org/content/reducing-tobacco-use-among-pregnant-wic-clients-increasing-enrollment-tobacco-cessation. Accessed October 10, 2024.
Background and Aim
Aim statement:
By July 31, 2013, increase by 18% (from 52% to 70%) the number of referred and enrolled pregnant WIC clients who use tobacco into a smoking cessation program through changes in the screening and referral process.
Need For The QI Initiative:
Research has shown that women who smoke during pregnancy increase the risk of pregnancy complications, premature delivery, low-birth-weight infants, stillbirth, and SIDS. If a mother smokes during pregnancy, her baby’s lung function is significantly reduced. Comparable with national data, within CDHD’s four-county service area, 10.7% of women smoked at “any time during pregnancy.” Although smoking rates among women have been decreasing in the United States, nearly one-quarter of women of reproductive age smoked in 2006.
In revising CDHD’s strategic plan, community assessments and local and state data were reviewed and indicated a great need for smoking cessation programs. In 2011, CDHD made one of its top agency strategic priorities “to decrease tobacco initiation and use.” In 2012, additional goals were added to this strategic priority, specifically pertaining to the proposed target population: “to reduce tobacco use among pregnant women enrolled in WIC.” CDHD has already committed agency resources to this public health problem and is dedicated to the aim of this project. CDHD has a great opportunity to reach an at-risk population to improve enrollment in smoking cessation programs and positively affect the life of the mother and the unborn child. The results of the Pregnancy Risk Assessment Monitoring System (PRAMS) indicate that efforts targeting pregnant women for smoking cessation have met some success; smoking rates have declined during pregnancy and after delivery. However, current smoking cessation efforts need to reach a greater proportion of pregnant women.
Area for Improvement:
WIC clients are at higher risk of smoking because of low socioeconomic status and lower education levels. CDHD’s current smoking cessation control efforts targeting pregnant WIC clients who smoke are not sufficient, enrolling only half of the eligible clients in the smoking cessation program. However, once enrolled in the program, more than half of the clients quit or reduce tobacco use. From January 2010 to May 2012, 224 pregnant WIC clients had completed the program. Of those who completed the program, 36% percent self-reported quitting tobacco use, with 16% reducing tobacco use at 6 months postpartum. Thus, CDHD needs a QI process to engage and enroll a greater number of pregnant women into the smoking cessation program.
Root Cause:
The following root causes identified in client focus groups helped to guide the discussion:
• Clients do not need to be told why they should quit; they already know.
• Text messaging is preferred for receiving communication.
• There is a lack of timely support and follow-up once clients have decided to quit; clients are also unaware of cessation resources in the community.
• Clients experience barriers to quitting, such as: smoking is part of their culture, friends and family members smoke, client has smoked from a young age, self-medicating, stress or anxiety, quitting is bad for baby and may cause miscarriage, and boredom.
The following root causes identified in the staff focus group's fishbone cause-and-effect diagram exercise were as follows:
• Clinic environment: lack of posters to promote, too many visuals competing for attention, prompts or checklists needed, lack of time.
• Staff: lack of knowledge, not comfortable counseling on cessation, lack of time, too much to do in an appointment, former or current smoker, not putting in notes for follow-up, lack of incentives.
• Clients: guilty feelings, health care provider says do not quit, self-sufficient—can quit on his or her own, friends and family smoked, previous unsuccessful quit attempts, not interested in quitting, perception that he or she can quit whenever he or she wants, fear of failure, friend was not successful in the program, frequent moves, no incentives, disconnected phone, tobacco cessation is not the reason he or she comes to WIC, group class not wanted.
• Policies/procedures: too much information to share during appointment time, client late, not in notes to follow up, lower priority, client-centered counseling, no simple checklist.
• Culture: smoking accepted in some cultures, it is not OK to be a smoker in others, religion, refugee “leader” accepts smoking, easy availability of tobacco.
• Resources: time, money, client incentives, program/curriculum, out of materials.
Planning and Execution Details
QI Implementation:
This project consisted of several rapid-cycle improvements (RCIs). After the steps of the PDSA process, the team evaluated the current process using a flowchart and fishbone diagram. Further analysis of the baseline data was completed by surveying clients to determine why they were not enrolling in the program. The results of this process indicated many root causes. Based on these results, the first intervention was to simplify the referral process by merging three forms into one and using a QuitLine fax referral to enroll clients who indicated they were ready to quit within 30 days.
The flowchart tool was used with a WIC staff focus group to identify the steps during a typical clinic visit and to determine how tobacco cessation fits within the clinic visit. The QI team learned that staff were expected to accomplish a large amount in the short clinic visit and that clinic procedure are inconsistent.
The fishbone cause-and-effect diagram was used with a WIC staff focus group to identify barriers to low enrollments in the WIC Quit Tobacco cessation program.
The WIC focus group brainstormed and prioritized solutions. The QI implementation team then researched and discussed the feasibility of the top three solutions. The most viable solution was presented to WIC staff, and the following tools were developed and secured to support the implementation of this solution: revised chart documentation form, one-page "barriers to quitting" handout, and the QuitLine fax referral form.
A flowchart outlining the new tobacco cessation referral process was created, used for staff education, and posted in the clinic as a visual reminder.
Goal of the project: Using the QI process, CDHD’s goal was to analyze the current approach of enrolling pregnant WIC clients in the smoking cessation program and to improve the process to increase enrollment. As smoking rates are higher among the younger population, CDHD would conduct focus groups for pregnant WIC clients in the following age groups: 15–19, 20–24, and 25–29 years. Approximately six women representing each age group would participate in each focus group. Discussion would elicit information about barriers and solutions to enrollment and participation in currently offered smoking cessation programs.
On February 21, 2013, tobacco cessation case studies were included in WIC staff training on participant-centered counseling conducted by a WIC-registered dietitian to prepare staff to guide clients toward meaningful goals based on identified risk factors.
On March 4, 2013, and April 2, 2013, two facilitated discussion and verbal survey client focus groups were conducted by a trained professional to determine reasons clients are not enrolling in the WIC Quit Tobacco cessation program. From January through April, WIC staff recruited clients to participate in the client focus groups. Invitations were first sent via postal mail. Invitations were sent via text messaging after little response from mailings and phone messages. The initial QI project proposal included offering several age-specific WIC client focus groups. Based on clients' limited availability, the focus groups became multi-age and were reduced to two. Even with dinner and a $40 gift card incentive, the number of clients who showed up for the focus groups was discouraging. Three were invited and confirmed attendance to the first focus group, and one attended. Eleven were invited and confirmed attendance to the second focus group, and only one attended.
Although it was not initially in the QI project plan, it became apparent that the QI team needed to include the WIC staff in the process of identifying why enrollment into the WIC Quit Tobacco cessation program was low. WIC staff focus groups, facilitated by the health promotion program manager and tobacco policy analyst, completed multiple QI tools: on January 17, 2013, a flow chart of the tobacco cessation counseling process within the WIC clinic visit; and on February 21, 2013, a fishbone cause-and-effect diagram for why enrollment numbers are low. On April 8, 2013, the WIC staff brainstormed and prioritized solutions.
The three-member QI implementation team, which included the health promotion program manager, the tobacco policy analyst, and the WIC program manager, used information gathered from the WIC client focus groups and WIC staff focus groups (QI tools) to develop an improvement theory.
During the June 6, 2013, WIC staff meeting, the tobacco policy analyst gave a QI project update and discussed the identified improvement plan. The staff received training on the identified improvement plan, which included reducing paperwork by merging three separate forms into one to make enrollment more streamlined, having WIC staff focus their counseling on barriers to quitting tobacco use, and referring clients within 30 days of readiness to quit to the Idaho QuitLine using a fax referral system.
During the June 2013 RCI and the Do, Study, Act phases of the PDSA process, several modifications were made to the initiative, including identifying the need to provide more training to help the staff understand the two parts of the project: clinic counseling of barriers to quitting and referral into QuitLine if a client is within 30 days of quitting. Other improvements were identified and implemented, including condensing three enrollment forms into one merged form, merging five separate barriers handouts into one, and creating a script that staff could use to engage clients.
From June 8 to July 24, 2013, weekly "huddles" with WIC staff took place to discuss implementation and to receive feedback on concerns, ideas, and observations.
Data collection proceeded as follows:
• In May 2013, pre-pilot data were gathered.
• In June 2013, pilot project data were captured.
• In July 2013, the procedure was finalized and data continued to be captured.
The following people were exposed to the QI initiative:
• WIC staff: 21 Boise staff members, 6 Mountain Home staff members, and 1 McCall staff member;
• 5 additional CDHD staff members: Jaime Harding, Joanne Graff, Rob Howarth, Russ Duke, and Hilary Flint-Wagner; and
• 14 WIC clients were invited to focus groups, and 28 pregnant tobacco users were introduced to the program.
QI Tools:
Other QI tools:
Focus groups
QI Tool Documentation:
Initiative Dates:
12/1/12 to 7/31/13
Initiative Duration:
Between 6-12 months
Methods of evaluation:
Data sources: The CDHD Quit Tobacco database, maintained by the health policy analyst and tobacco cessation expert, Joanne Graff, will be the primary data source used to measure changes in smoking cessation program enrollment. The focus group professional (to be hired) will be required to submit his or her report to the project administrator (Nikki Zogg) and to participate in a face-to-face meeting with all CDHD staff involved with this project. Additionally, Jeff McCullough, a CDHD intern, will be assigned to compile and analyze the process change feedback data from CDHD WIC employees after implementation of the QI process.
The QI team used the following tools to measure the impact of the QI initiative:
• Idaho Department of Health and Welfare QuitLine data generated by provider Alere.
• CDHD Quit Tobacco database maintained by Joanne Graff, the tobacco policy analyst and tobacco cessation expert.
• Pre-pilot QI data capturing form, used from May 1 to 31, 2013. In 23 days, 63 pregnant clients were seen in the WIC clinic; 8 were tobacco users. Seven (88%) were referred to the WIC Quit Tobacco cessation program, and 4 (57%) accepted the referral.
• Pilot QI data capturing form, used from June 10 to July 5, 2013. In 19 days, 36 pregnant clients were seen in the WIC clinic; 7 were tobacco users. Six (86%) were referred to the WIC Quit Tobacco cessation program, and 3 (50%) accepted the referral. Five (71%) were referred to the QuitLine, and 1 (20%) accepted the referral.
• QI data capturing form. The team finalized the data collection procedure and continued to capture data from July 8 to 26, 2013. In 15 days, 65 pregnant clients were seen in the WIC clinic; 15 were tobacco users. Thirteen (87%) were referred to the WIC Quit Tobacco cessation program, and 5 (33%) accepted the referral. Ten (67%) were referred to the QuitLine, and 4 (40%) accepted the referral.
• The Southwest District Health Department 2001 Study on WIC Client Participation in Tobacco Cessation Program helped the QI team to glean relevant information that was useful in confirming root causes.
Supplemental Materials:
Storyboard
Supplemental Files:
| Attachment | Size |
|---|---|
 CDHD QI Storyboard 08_29.pdf | 1.25 MB |
Results
Measurable QI Outcomes:
The goal was to increase the number of pregnant, tobacco-using WIC clients who enrolled in tobacco cessation services. The QI team did not achieve its goal.
Aim statement: By July 31, 2013, increase by 18% (from 52% to 70%) the number of referred and enrolled pregnant, tobacco-using WIC clients in a smoking cessation program through changes in the screening and referral process.
The following data are available on the number of enrolled clients:
• before the QI project, 52% were enrolled in WIC Quit Tobacco;
• at the pre-pilot stage, from May 1 to 31, 88% were referred and 57% were enrolled in WIC Quit Tobacco;
• at the pilot stage, from June 10 to July 5, 86% were referred and 50% were enrolled in WIC Quit Tobacco; and
• at the pilot stage, from July 8 to 26, 87% were referred and 33% were enrolled in WIC Quit Tobacco.
From June 7 through July 31, 2013, 12 clients were referred to the QuitLine program. Of these, 9 (75%) accepted referral, and QuitLine made 5 attempts to contact them. Two (22%) clients were reached, and they both enrolled in the QuitLine program.
Other QI Outcomes:
Other QI outcomes included the following:
• Merged information from three WIC Quit Tobacco forms used for client enrollment was merged into one form.
• A simplified chart documentation form was developed.
• Per WIC staff request, the barriers handout is now one page rather than five separate half-page sheets.
• The QI team added a fax referral to the QuitLine if a client is within 30 days of being ready to quit tobacco use. This referral will enable clients to receive immediate and frequent cessation interventions from a trained cessation counselor.
The role of the WIC staff changed somewhat from being the primary provider of cessation counseling to providing more emphasis on counseling, barriers to quitting, and encouraging clients to quit.
Lessons Learned, Observations and Insights:
The QuitLine can provide tobacco cessation counseling in multiple languages to reduce health disparities.
WIC was involved in another referral-type program during the QI project. A WIC breastfeeding peer counseling study began on October 15, 2012, and WIC staff were actively involved in recruiting into the program until June 15, 2013. In the limited time for WIC appointments, this task was an additional time commitment and created an additional process that in some ways competed with the prenatal tobacco cessation recruitment.
The QI team learned to be flexible and willing to change based on what was learned during the process. Flexibility is also important when dealing with staff turnover and time constraints. The QI team also learned to involve staff affected by the project to garner insight and buy-in.
Future Plans:
By the end of the project, although the referral rate remained fairly constant rather than increasing, staff knowledge improved, and clients received enhanced tobacco cessation services through QuitLine referral. Plans include expanding the improved enrollment process and QuitLine fax referral to all WIC clinics within the CDHD area. Staff will continue to monitor program effectiveness and implement additional improvements as needed.
Training and Preparation
Technical Assistance Received:
This QI project was conducted as part of the National Network of Public Health Institutes (NNPHI) QI Award Program, a competitive initiative that provides a small financial award and 15 hours of distance-based and in-person coaching from a designated QI consultant. The program is part of the Community of Practice for Public Health Improvement (COPPHI), supported by the Robert Wood Johnson Foundation.
QI Related Training Received:
This QI project was conducted as part of the National Network of Public Health Institutes (NNPHI) QI Award Program, a competitive initiative that provides a small financial award and 15 hours of distance-based and in-person coaching from a designated QI consultant. The program is part of the Community of Practice for Public Health Improvement (COPPHI), supported by the Robert Wood Johnson Foundation.
In December 2012, Joanne Graff (tobacco policy analyst) attended a 1.5-day QI-focused Open Forum hosted by NNPHI, which was preceded by an 8-hour QI skill-building workshop.
QI team members participated in four NNPHI webinars and attended conference calls with the QI coach (Joe Kyle) provided by NNPHI.
Information about the Community
Population Size:
Population Characteristics:
Idaho’s counties are divided into seven local public health districts (LHDs). CDHD provides services to a four-county area (Ada, Boise, Valley, and Elmore Counties) and promotes a vision of “healthy people in healthy communities.” CDHD employs 124 full-time staff members and provides the following services: immunizations, reproductive health, health promotion and health policy, communicable diseases, WIC, and environmental health. The estimated population of Ada County is 409,061 (U.S. Census, 2012). The other three counties that CDHD serves are rural and frontier, and they include a total population of approximately 43,000.
Elmore County demographics indicate that 88.7% of the population is Caucasian, and 15.7% is Hispanic or Latino. Of the population, 28% are younger than 18 years, and 10.8% are 65 or older. In Elmore County, 14% of residents fall below the national poverty line, and 22% of children younger than 18 years are reported to be living in poverty. As of June 2013, 12.9% percent of Elmore County residents used the Supplemental Nutrition Assistance Program (SNAP) (food stamps). Only 14.6% of residents have a bachelor’s degree or higher, and the unemployment rate is 9.3%. The adult smoking rate in Elmore County is 19% compared with the Idaho state average of 18%.
Boise County is home to both rural and frontier populations and is located in southwestern Idaho. Of the population, 20% are younger than 18 years, and 19.1% are older than 65 years. Of county residents, 23% report excessive drinking, a limited number of mental health providers are available in the county. The average number of mentally unhealthy days reported in the past 30 days is 4.4. Of residents in Boise County, 29% are obese—higher than the state average of 26.9%. Of adults aged 20 or older, 20% report no leisure time activity and have poor access to recreational facilities. Only 33% of Boise County residents have access to healthy foods, compared with 52% in the state of Idaho. The adult smoking rate in Boise County is 20% compared with the Idaho state average of 18%. Of Boise County residents, 10% used SNAP (food stamps) in June 2013.
Valley County is home to both rural and frontier populations. Of the population, 18% are younger than 18 years, and 19.1% are 65 years or older. Of adults in Valley County, 21% reported smoking every day or most days. Of adults in Valley County, 28% were classified as obese. Of Valley County adults, 24% report no leisure time activity. Of adults, 19% report excessive drinking, and the county is designated as a mental health professional shortage area. The average number of mentally unhealthy days reported in the past 30 days is 2.6. The birth rate among teenagers is 34 per 1,000 of the female population ages 15–19. Of Valley County residents, 71% graduated from high school compared with the Idaho average of 81%. In June 2013, 7% of Valley County residents used SNAP (food stamps).
Ada County is home to primarily urban populations. Approximately 26% of the population is younger than 18 years, and 11.4% are 65 years or older. The adult smoking rate is 16%, and the obesity rate is 23%. Of Ada County residents, 84% graduated from high school. Of Ada County residents, 11% used SNAP (food stamps) in June 2013.
The district covers an area of 9,677 square miles. The geography of the district ranges from flat desert and rolling hills to rugged mountains. The terrain, small isolated communities, and rural nature of much of the district presents distinct challenges to providing comprehensive, easily accessible, and quality public health services to all residents. The population is divided between 88% living in urban areas and 12% in rural.
Information about the Health Department
Local/State Relationship:
Decentralized
Local Health Department Governance:
Local Governance - all LHDs in the state are units of local government
PHAB Accreditation Status:
Not planning to submit application in the next 3 years
Annual QI Initiative Frequency:
QI activity level:
Organization Type:
QI Staff Information
Total number of Staff on QI Team:
3
Total number of FTEs on QI Team:
0.15
QI team members:
Role in the Initiative:
Co–project manager/lead implementer
Role in Organization:
Health Policy Analyst
FTE:
0.10
Name (Optional):
Joanne Graff
Role in the Initiative:
Co–project manager
Role in Organization:
Health Promotion Program Manager
FTE:
0.05
Name (Optional):
Jaime Harding
Role in the Initiative:
Strategy implementation and integration
Role in Organization:
WIC Program Manager
FTE:
0.05
Name (Optional):
Angela Spain
Accreditation Details
PHAB Standards:
Domain 1: Conduct and disseminate assessments focused on population health status and public health issues facing the community›Standard 1.4 Provide and Use the Results of Health Data Analysis to Develop Recommendations Regarding Public Health Policy, Processes, Programs, or Interventions›Measure 1.4.1 A Use data to recommend and inform public health policy, processes, programs, and/or interventions
Domain 4: Engage with the community to identify and address health problems›Standard 4.2 Promote the Community’s Understanding of and Support for Policies and Strategies That will Improve the Public’s Health›Measure 4.2.1 A Engage with the community about policies and/or strategies that will promote the public’s health
Domain 7: Promote strategies to improve access to health care services›Standard 7.2 Identify and Implement Strategies to Improve Access to Health Care Services›Measure 7.2.1 A Convene and/or participate in a collaborative process to establish strategies to improve access to health care services
Domain 7: Promote strategies to improve access to health care services›Standard 7.2 Identify and Implement Strategies to Improve Access to Health Care Services›Measure 7.2.2 A Collaborate to implement strategies to increase access to health care services
Domain 7: Promote strategies to improve access to health care services›Standard 7.2 Identify and Implement Strategies to Improve Access to Health Care Services›Measure 7.2.3 A Lead or collaborate in culturally competent initiatives to increase access to health care services for those who may experience barriers due to cultural, language, or literacy differences
Domain 9: Evaluate and continuously improve health department processes, programs, and interventions›Standard 9.2 Develop and Implement Quality Improvement Processes Integrated Into Organizational Practice, Programs, Processes, and Interventions›Measure 9.2.1 A Establish a quality improvement program based on organizational policies and direction
Domain 9: Evaluate and continuously improve health department processes, programs, and interventions›Standard 9.2 Develop and Implement Quality Improvement Processes Integrated Into Organizational Practice, Programs, Processes, and Interventions›Measure 9.2.2 A Implement quality improvement activities
Collaborations
Partner Organizations:
N/A
Contact Information of the Submitter
First Name:
Joanne
Last Name:
Graff
Organization:
CDHD
Submission Status:
Completed
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Comments
Great project! Reducing
Great project! Reducing smoking during pregnancy is so important for future maternal and child health. In KY our rates are very high. Are you willing to share your one-page barriers handout that was developed during this project? You have inspired me to take a look at our WIC processes for referring and counseling pregnant smokers.
Public Health Services Manager
Clark County Health Department, KY
bethv.willett@ky.gov
www.clarkhealthdept.org
@CCHealthDept