Crawford County has abnormally high rates of women who smoke during pregnancy This issue needs to be addressed

d on a community level Public health nursing needs to get involved to help correct this serious issue

Crawford County 47.4% rate of smoking during pregnancy Local counties: Oceana 16.9% in 2006; Lake County 31.5% in 2006; Kalkaska County 29.9% in 2006; Mason County 18.8% in 2006 (Kids Count Data Books, 2013) State of Michigan 19.3% rate of smoking during pregnancy

Influencing factors: Poverty stricken county: 30.1% living at poverty level Young mothers: Age 18-24 24.6% Education: 37.2% GED holders Data supports need for community nursing intervention The group of women who are particularly affected by this problem: young, single mothers, with little to no education who live in poverty. Dorothea Orems self-care theory helps explain the difference

Multiple smoking cessation support programs Managed care plans Online resources Resources sufficient The problem is ongoing and continues to exist among women who smoke related to the strength of the addiction, denial, and for the fact that in the community it is the popular choice

Interdisciplinary team members:

Registered Nurses Registered Dietitians/Nutritionists Social workers Physicians Counselors Psychiatrists (in some cases)

WIC: Women, Infants, and Children Local health care system support group Hospital birthing classes Hospital baby care classes Church food pantry Salvation Army

Who: Unborn children are at risk for preterm birth, birth defects, low birth weight and sudden infant death syndrome. What: If the mother smokes cigarettes during pregnancy. Changeable Factor: Stop smoking during pregnancy Measurable Indicators: Infants born with healthy birth weights, less birth defects and delivery at full term.

In

2011, 10.5% of all infants born in Crawford county had low birth weight. 9.6% were born preterm. 47.4% of mothers smoked during pregnancy. (Michigan Department of Community Health, 2012)

Lower levels of education and higher rates of smoking are directly related(Schnohr, et al., 2004).
In Crawford County, 19% of live births in 2011 were to mothers with less than 12 years of education (District Health Department #10, 2013).

Smoking prevalence is higher among those living below the poverty level, 32% smoke (Oral Cancer Foundation, n.d.).

In Crawford County , 27% of the 5-17 year olds live in poverty and 70% of births are paid for by Medicaid, a low income state funded insurance (District Health Department #10, 2013).

When smoking is socially accepted it is harder to see the negative or potential effects on an unborn child.
Michigan is ranked 26th among all states of adults who smoke,

23% (Centers for Disease Control and Prevention, 2013) .

Direct

Indirect

Normal birth weights Less birth defects Fewer SIDS deaths Full term pregnancy

Lower delivery costs Less need for neonatal ICU care Healthier families Lower rates of respiratory problems at birth Lower asthma among pediatrics who are born to mothers who smoke

Located close to highways and hospital. Features Au Sable River, local camp grounds, outdoor recreational opportunities, and an assortment of religious organizations. Tourism and agriculture are the biggest sources of industry. ("Community health needs," June) Survey opinions show that residents feel they have a willingness to cooperate with one another to improve the community. Biggest Weaknesses are problems with the economy, which include lack of businesses and jobs.. The percentage of persons below poverty in Crawford County is higher than in Michigan. (Brown, Johnson, Tabarovky, Voss & Colarelli )

Unborn children with mothers who smoke during pregnancy have the risk of preterm birth, birth defects, low birth weight and SIDS (Sudden Infant Death Syndrome) The extent of the problem is evidenced by the high rate of smoking during pregnancy in Crawford County. Smoking Cessation Programs are available, however woman continue to smoke. The strength of the addiction combined with the fact that many pregnant women smoke in this community may lesson the fear associated with the behavior.

The Michigan Maternal Infant Health Program is a home visiting program that targets Women, as well as the health outcome of the unborn child. The following description is retrieved from the website, MIHP is a program for all Michigan women with Medicaid health insurance who are pregnant and all infants with Medicaid. It is a benefit of their insurance. MIHP provides support to promote healthy pregnancies, good birth outcomes, and healthy infants. The goal of MIHP to reduce maternal and infant morbidity and mortality. ("Department of community," ) On going training for public health nurses and clinicians is of crucial importance in the prevention of smoking and smoking cessation for Crawford County woman. Smoking cessation interventions using the 5 As have proven effective to reduce or eliminate smoking. Nurses should become familiar with this strategy and employ it to deliver evidence based practice to clients.

1.

2.

3.

4. 5.

Ask In this step the nurse is to ask the patient about her smoking status. The rational is to determine at what stage of change the client is in. The best time to ask is during the initial health history collection. Advise This step should advise all clients to quit smoking in a clear, strong , and personalized way. Incorporate a positive non- confrontational approach. Acknowledging the difficulty involved in quitting is helpful to communicate support Assess This step assesses the extent to which the client wants to quit or if the client does not wish to quit at all. Motivation strategies should be used depending on the assessment. Assist In this step the nurse should help to set a quit date, offer self help materials, and support. Arrange Follow up visits should be made and smoking status assessed at each follow up visit. Contact client by telephone to offer support. If cessation is not successful encouragement, support, and sources for help made available at all telephone contact visits and in person follow up visits. Goal: The client will reduce by or eliminate completely, the number of cigarettes smoked by the first follow up visit in one week at first follow up visit and again at one month intervals. Objective: Decrease or eliminate harm to unborn child as quickly as possible. Objective: Assess clients smoking status and need for further assistance

The 5 A's are:

 Tracking

mechanisms to monitor for noticed change within months

Self-reported surveys of incidence of

smoking and successful cessation Use of tobacco quit lines (phone counseling) Participation in the free 6 week program offered by the MIHP staff (DHD10) Utilization of Crawfords community strengths as resources strong religious affiliations, sense of community closeness, outdoor recreation

Tracking mechanisms to monitor for changes that occur over 1 to 5 years

Rates of low birth weights Rates of infant mortality Documentation of clinicians consistently using

the 5 As throughout the ENTIRE pregnancy Cost analysis to show interventions have been cost-effective (intervention costs exceed maternal smoking related healthcare costs) Meet the Healthy People 2020 target of 1.4% reduced from Crawfords 45.5% females who smoke while pregnant (MDCH, 2012)

To effect change, guidelines must be coupled with strategies to improve their acceptance and feasibility. Such strategies include enlisting the support of local opinion leaders, using reminder systems for clinicians and patients, adopting standing orders, and audit and feedback of information to clinicians about their compliance with recommended practice (AHRQ, 2009).

Meet and report progress to Crawford Countys community agencies, stakeholders, and representatives Provide additional recommendations to maximize effective use of resources based on evidence of effectiveness shown (CPSTF, 2013) Mass-reach health communication interventions to create awareness Broadcast time on the radio, graphic images to generate emotional responses on TV, billboards, and print media Interactive mobile phone-based interventions

Address underlying causes of behavior specific to Crawford County poverty, high school drop-out rate

Inform

Educate

Empower

Agency for Healthcare Research and Quality. (2009). Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: U.S. Preventive Services Task Force reaffirmation recommendation statement. In National Guideline Clearinghouse. Retrieved October 30, 2013, from http://www.guideline.gov/content.aspx?id=14339 Brown, M., Johnson, V., Tabarovky, S., Voss, B., & Colarelli , S. (2011). Grayling community survey results. Retrieved from: http://graylingchamber.com/wpcontent/uploads/2011/11/Grayling-Community-Survey-Results.pdf Community health needs assessment for Roscommon, Oscoda, and Crawford counties. (June, 2012). Retrieved from: http://www.mercyhealthgrayling.com/documents/Grayling/Mercy Hospital Grayling CHNA.pdf Community Preventative Services Task Force. (2013, September 13). Reducing tobacco use and secondhand smoke exposure. In The Community Guide. Retrieved October 30, 2013, from http://www.thecommunityguide.org/tobacco/index.html Centers for Disease Control and Prevention. (2013, May 1). State Highlights: Michigan. Retrieved from http://www.cdc.gov/tobacco/data_statistics/state_data/state_h ighlights/2012/states/michigan/index.htm Department of community health;maternal infant health program. (n.d.). Retrieved from http://www.michigan.gov/mdch/0,4612,7-132-2943_4672-106183--,00.html

District Health Department #10. (2013). DHD #10 Community Stats. Retrieved from http://dhd10.org/dhd10-community-statistics Kids Count Data Books. (2013). Births to mothers who smoked during pregnancy. Retrieved from http://datacenter.kidscount.org/data/tables/1655-births-to-mothers-who-smokedduring-pregnancy?loc=24&loct=5 Michigan Department of Community Health. (2012, December 22). Characteristics of the Mother or Infant, as a Percentage of Live Births. Retrieved from http://www.mdch.state.mi.us/pha/osr/chi/births/Birthchar/BxChar.asp?DxId=1&CoCode =20&CoName=Crawford Michigan Department of Community Health. (2012, April 2). Crawford County Health Profile Chartbook. In District Health Department #10. Retrieved October 30, 2013, from http://dhd10.org/dhd10-community-statistics Nursing Theories. (2012, February). Dorothea Orem's self-care theory. Retrieved from http://currentnursing.com/nursing_theory/self_care_deficit_theory.html Oral Cancer Foundation. (n.d.). Demographics of tobacco use. Retrieved from http://oralcancerfoundation.org/tobacco/demographics_tobacco.htm Phelan, S., Albrecht, S., Melvin, C., Rohweder, C., Laping, J., Chapin, J., & Mahoney, J. (2011). Smoking cessation during pregnancy;a clinicians guide to helping pregnant women quit smoking. Retrieved from :http://www.acog.org/About_ACOG/News_Room/~/media/Departments/Tobacco Alcohol and Substance Abuse/SCDP.pdf Schnohr, C, Holbjeere, L, Riegels, M, Ledet, L, Larsen, T, Petersen, L, & Prescott, E. (2004). Does educational level influence the effects of smoking, alcohol, physical activity, and obesity on mortality? A prospective population study. Scandinavian Journal of Public Health, 32(4), 250-256.