Home Health Care Nurses as a New ChannelFor Motivating Smokers to Quit

Outline • Why is it so difficult to change behavior? • The importance of theory • Motivational Interviewing as a vehicle to delivery theory based interventions • Applications Home Health Care Nurses as a New Channel For Motivating Smokers to Quit • Randomized and trained home care nurses (N=98) to deliver one of two smoking cessation interventions to their patients who smoke: • Motivational Interviewing + Biomarker Feedback • Standard Care (SC) Funded by R01 CA74553 Borrelli, Novak, et al. (2005) Preventive Medicine Biomarker Feedback • Biological indices of physical harm, disease, or increased disease risk • Use MI as a vehicle to deliver biomarker feedback to increase motivation to change health behavior. Basic Science Discoveries Health Behavior Theory Motivational Intervention Health Behavior Change Carbon Monoxide Feedback • CO binds to haemoglobin to form COHb • This prevents red blood cells from carrying oxygen • Smokers may have 10% of their blood cells taken up by CO, depriving the body of O2. • Intervention: Provide CO level, discussion of symptoms, and how the body repairs itself after quitting. Risk Perception Theory BedFont Smokelyzer 20 minutes after: Blood pressure and heart rate drop to normal  Body temperature of hands and feet increases to normal  What happens when you Stop Smoking * 24 hours after:  Chance of heart attack decreases. 8 hours after:   Carbon monoxide level in the blood drops to normal Oxygen level in the blood increases to normal 48 hours after:  10 years after quitting:  Lung cancer death rate for average smoker drops to 12 per 100,000 almost the same as the rate for nonsmokers  Pre cancerous cells are replaced  Other cancers – such as those of the mouth, larynx, esophagus, bladder, kidneys, and pancreas – decrease.  There are 30 chemicals in tobacco smoke that cause cancer.  2 weeks – 3 months:  Circulation improves.  Walking becomes easier.  Lung function improves by up to 30% 72 5 years:  Nerve endings start to regrow Ability to smell and taste improves. Lung cancer death rate for average smoker (1 pack a day) decreases from 137 per 100,000 to 72 per 100,000 * Geriatrics April, 1993, Vol. 48(4) hours: Bronchial tubes relax making breathing easier.  Lung capacity increases  1 - 9 months:   Coughing, sinus congestion, shortness of breath decrease. Cilia regrow in lungs, increasing ability to handle mucus, clean the lungs, and reduce infection. Intervention Mapping for Social Cognitive Theory Concept Definition Goal setting Personal regulation of goalSelf-monitoring, goal setting, problem directed behavior or performance solving, and subgoals. Reinforcements Responses to a person’s behavior Self-initiated rewards and incentives for that increase or decrease the achieving both large and small goals. likelihood of reoccurrence Motivation Importance and desire to change MI; pros/cons of change Self-efficacy The person’s confidence in performing a particular behavior Small steps; seek specificity about the change; modeling, encouragement Outcome Expectations Behavioral Coping Belief that performance of behavior leads to desired outcome. Strategies used to deal with emotional stimuli Intervention Reframe past failures as learning experiences; focus on small + change. Problem solving and stress management; practice skills in emotionally arousing situations. Relapse prevention. Designing for Dissemination: Community based Participatory Research Informal meetings with VNA nurses and management 1. • • • Needs Assessment JAHCO beginning to emphasize smoking counseling PI goes on home care visits Focus groups 2. • • • • Barriers to intervention delivery (nurse, system) Attitudes and beliefs about smoking Reactions to the program Development of prototypes of intervention guides Pilot Intervention Focus groups 3. 4. • • Field experiences Reactions to using the pocket guide *Funded by The Robert Wood Johnson Foundation % Quit Smoking, Bioverified Continuous Abstinence TIME End of treatment 2 month f-u 6 month f-u 12 month f-u SC 0.7% 2.3% 3.2% 4.4% MI 1.7% 6.0% 5.3% 8.7% O.R 2.3 2.7 1.6 2.0 95% C.I. 0.2-26.5 0.7-11.1 0.5-6.2 0.6-6.4 O.R 1.2 0.9 1.1 1.5 95% C.I. 0.5-2.9 0.4-2.3 0.4-2.5 0.6-3.6 (7) Day Point Prevalence Abstinence TIME End of treatment 2 month f-u 6 month f-u 12 month f-u Borrelli, Novak, et al. (2005) Preventive Medicine SC 7.9% 9.6% 10.3% 8.7% MI 9.3% 9.5% 11.3% 12.5% Impact = Treatment Efficacy X Population Reach Intervention Type Efficacy Reach Impact (% Quit) (% pop) (10(ExR)) Ideal Intervention 100% 100% 1.00 Reactive: Clinical Tx + pharmacological 30-40% 3-5% .09-.20 Proactive: primary care/dental + pharmacological 10-20% 10-30% .10-.60 Project CARES 12.5% 30% .38 (Abrams, et al., 1996; Borrelli et al., 2005) Reducing SHSe in Children with Asthma •40% of children are exposed to SHSe in the home (Homa et al., 2015) •47% of kids with asthma live in multiple-smoker households (Borrelli et al., 2014) •Higher SHSe related to greater asthma functional morbidity (Fedele, Tooley, Busch, McQuaid, Hammond & Borrelli, 2015). •Studies addressing only SHSe reduction: •parents remain smokers •SHSe is sustained •Risk of children smoking •Combination of SHSe reduction and smoking cessation: less effective (Rosen et al., 2012; 2014). •Focused on parental smoking cessation Rationale for the Study Utilize a teachable moment to motivate parents to quit smoking. Raise awareness of the risks of smoking to themselves. Raise awareness of the multiple effects of SHSe on children’s asthma: -Increased risk for developing asthma -Decreased lung function -Increased asthma symptoms -Increased utilization of medical services -Increased medication use Smokers with Asthmatic Children BAM • Problem Solving • Coping Skills • Goal setting • Reinforcement • Didactic & Educational PAM • Increase risk perception of smoking to self and child • Biomarker feedback • CO • Second hand smoke exposure • 3 home visits • 30-45 minutes • Follow-up call Mediator • Self efficacy • Motivational interviewing Mediator • Risk perception Primary Outcomes: Quit smoking, SHS reduction Secondary Outcomes: Asthma Morbidity Funded by The Robert Wood Johnson Fdn NHLBI R01 HL62165 & R01 HL062165-06 to B. Borrelli Teachable Moment and Biomarker Feedback Motivational Phase Connecting Illness/Risk of Illness to Behavior Action Phase Motivation to Change Symptoms Illness, or Risk Behavior -Education -Skills -Goal Setting (e.g, Smoking, not taking meds) Motivational Intervention + Biomarker Feedback Risk Perception Theory -Vulnerability -Optimistic Bias -Precaution Effectiveness Self-Efficacy Behavior Change Intervention Mapping: Precaution Adoption Process Model Examples Stage 1: Has heard of hazard I have heard that giving my child soda causes cavities. Stage 4: Decides to take action (Intention only) I have plans to stop purchasing soda for my family. Beliefs about seriousness of threat (severity) Precaution effectiveness; contexual factors Communicat Personalized risk Self-efficacy Risk factor ion about the information about how soda information for self. enhancement hazard. Problem solving Motivational consumption may be Barriers counseling Interviewing affecting their child techniques to reduce Family counseling counterarguing and belief perseverance. Mediators of Knowledge of risks stage movement Intervention components Stage 2: Believes that Stage 3: Believes hazard poses risk to others that hazard poses personal risk Other children drink lots of Soda consumption is soda and their teeth are bad for my child’s affected oral health Reduction of optimistic bias Cost/benefits of soda consumpton; personal vulnerability. Stage 5: Takes Precaution I have stopped purchasing soda for my family. Complexity of precaution Ease of change Cost of precaution adoption Feedback on Secondhand Smoke Exposure • Passive nicotine monitors utilize nicotine as a tracer for SHS • Nicotine, a weak base, passively diffuses into the filter treated with sodium bisulfate, a weak acid, forming a stable salt. • Analyzed by gas chromatography with nitrogen selective detection • Home & child monitors placed for one week. Hammond et al., 1995; Hammond and Leaderer, 1987 Sampler Results - Maria Sampler Results: Your Home 10 7 6 5 4 3 high 2.5 2 moderate Number of Cigarettes Smoked 8 8.0 Smoke Exposure Level 9 3 1.5 1 Less than 1/4 cig 2 0.5 1 low 0 Maria Child of Non-Smoker 0 Your Home Maria breathed in as much smoke as if she smoked eight cigarettes the week that the sampler was placed. Non-smoker's Home The level of smoke in your home usually reached very high levels, compared to a non-smoker’s home. PAQS Study Outcomes PAQS Latino TIME 2 month post-tx 3 months post-tx BAM 9.2% 12.3% PAM 20.5% 19.1% O.R 2.54 1.68 95% C.I. Cohen’s d .91-7.10 .64-4.37 .32 .18 PAQS TIME BAM PAM O.R 95% C.I. 2 month f-u 9.7% 20.2% 2.36 1.0-5.43* 6 month f-u 6.5% 8.5% 1.4 0.4-4.0 12 month f-u 4.3% 11.7% 2.9 0.9-9.6 p=.07 Intensity Hypothesis • Additional phone counseling + biomarker feedback: • Doubled smoking cessation rates (18.2% vs. 9.9%) (OR=2.12, 95% CI =1.09-4.12) • Resulted in better child asthma outcomes • 81% lower odds of hospitalization for asthma (OR=.19, 95% CI .04-.89) • 52% lower odds of missed school due to asthma (OR=.48, 95% CI .24-.98). • 39% lower odds of asthma symptoms (OR=.61, 95% CI .39-.96) Dissemination of PAQS • 16 Baltimore City Head Start Programs • n=330, Randomized to Education vs. PAQS • 93% African American • At 12 months post-intervention, the PAQS group: • Lower household air nicotine levels • More household smoking bans • Lower child salivary cotinine among those with household smoking bans • MI resulted in significant cost savings from averted ED visits • ($4,410 SI: $2241-$6626) Teachable Moment  Naturally occurring life transitions or health events that have the potential to motivate people to adopt risk reducing health behaviors. People may be more receptive to health risk messages because of the context of more heightened awareness regarding their health. Naturally occurring event primes the individual to consider change. Low cost widely disseminable interventions tip the balance in favor of change. PAQS 3: Teachable Moment Results Parents of children with asthma achieved greater cessation vs. parents of Healthy Children after receiving identical biomarker feedback interventions. Asthma Healthy OR 95% CI 7 day ppa 14.6% 6.4% 2.26 1.13-4.51 30 day ppa 12.9% 5.0% 2.60 1.22-5.54