HEALTH NEEDS ASSESSMENT OF PREGNANT WOMEN IN NORFOLK ADDICTED TO TOBACCO SMOKING

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HEALTH NEEDS ASSESMENT OF PREGNANT WOMEN IN NORFOLK ADDICTED TO TOBACCO SMOKING

BACKGROUND
Smoking is one of the leading causes of avoidable deaths in the United Kingdom. Treatments for smoking related illnesses financially burden the NHS (National Health Service) an estimated £1.5 billion per year (Twigg, 2004). Smoking, in general terms, is the inhalation of smoke from burning tobacco- and may be in the form of cigarettes, pipes and/ or cigars. A smoking habit is a physical addiction to such tobacco products; several health experts support that habitual smoking is a psychological addiction and one with adverse health consequences. Leventhal and Zvolensky (2015) claimed that emotional vulnerabilities link anxiety and depression to smoking; individuals may either be casual or social smokers, but such vulnerabilities have been shown to exist in both such groups.  Despite the existence and awareness of targets to reduce smoking during pregnancy in the United Kingdom, the practice remains rather widespread. In a survey done in 2013, 11 percent of pregnant women aged 16 to 49 were identified as smokers and 34 percent as ex-smokers (Statistics on Smoking, 2015). Therefore, active research in terms of understanding the needs of pregnant smokers may be required along with providing them with appropriate support to help them quit the dangerous habit. The current assignment explores the health needs of pregnant women who smoke in Norfolk, United Kingdom.  The concept of “need” is one of subjectivity, variability and constant change (Cowley et al., 2000). There are many different theoretical understandings of what needs are, and in ways to solve them. These include; Ponsioen (1962), who asserts that, it is society’s first responsibility to meet the basic survival needs of its members (biological, social, emotional and spiritual); Maslow’s (1943) Hierarchy of Needs defines the needs of life in an order in which needs have to be satisfied (Kendall and Bryar, 2012). Therefore, basic needs must be satisfied before higher needs, to enable individuals to reach their full potential (Thrower, 2002). In order to address the health issues that arise due to smoking during pregnancy for mothers and neonates, health needs assessments needs to be undertaken.
Smoking is the leading preventable cause of morbidity and death among infants and women (Coleman et al., 2012). The known adverse effects during pregnancy and birth outcomes associated with smoking during pregnancy such as placental abruption, miscarriage, congenital abnormalities, low-birth weight, neonatal and sudden infant death as well as increased risks of congenital anomalies, smoking during pregnancy remains prevalent (Hackshaw et al., 2011). Several women continue smoking throughout their pregnancy period, with approximately 17% in England and Wales and 14% in the United States (Tong et al., 2009). Beenstock et al., (2012) reported how around 5000 miscarriages and 300 perinatal deaths per year result from maternal smoking in the UK. The true prevalence of maternal smoking during pregnancy however is likely to be much higher, as under-reporting by mothers who smoke is apparent due to the stigma attached to smoking during pregnancy. The detrimental effects of smoking during pregnancy are not only physiological, but they also include negative consequences on educational and behavioural performance such as issues related to hyperactivity and attention (Lumley et al., 2015).  Additional negative consequences encompass increased risk of respiratory infections, asthma, high blood pressure and early onset of diabetes. Pregnant women are also more likely to continue to smoke throughout their pregnancy if they live in a household with presence of other smokers (Owen and Penn, 2002). Research has also shown that having a partner who smokes results in a higher relapse rate amongst pregnant women making it much harder for them to quit (Fang et al., 2004).The cessation of smoking during pregnancy is thus crucial for both maternal and foetal health (Coleman et al., 2012).
 
HEALTH NEEDS ASSESSMENT
Thus, there is a health need, which needs attention in this particular area. Recognising the health needs of people and communities leads to the availability of flexible health services, with increased accessibility. Carrying out health needs assessment requires careful preparation, the availability of relevant information and clear and effective communication across multidisciplinary teams (Jack and Holt, 2008). A health needs assessment is a systematic method that helps identifying the unmet healthcare needs of a population and then allows the making of changes to address those unmet needs. It is an assessment that aims to improve health, encompassing the concept to benefit from an intervention. A needs assessment helps to guide decision-making, providing a systematic perspective for decision-makers, allowing for implementing interdisciplinary solutions for complex solutions. Maslow’s hierarchy of needs (1943) and Bradshaw’s classification of needs are two pivotal assessment tools to many health care needs, thus helping to prioritise and address unmet needs. The theory of Humanism states that we are all seeds with the potential to grow- provided all our needs met. Maslow proposed the Hierarchy of Needs in an attempt to address what human beings need. The needs depicted as a pyramid, as he believed that certain needs are more fundamental before other needs manifest. Bradshaw’s classification focuses on four main needs: 1) Felt– the individuals perceptions of variations from normal health, 2) Expressed- this is when the individual seeks help to overcome any variations from their normal health, 3) Normative- this involves the professional defining interventions appropriate to address the expressed need, and 4) Comparative- a comparison between needs for size, severity, cost etc. is undertaken (Bradshaw, 1994).
The concept of “health needs” is relatively recent, especially in respect to components such as health promotion or public health. The objective of health needs assessments is to reduce health inequalities, as well as in improving population health (Porter, 2005). Various factors such as lifestyle, genetic predispositions, stress and ecological environment affects Individual health needs. Hence, a holistic approach that does not focus on just a single problem or issue is required as health needs assessment remains a complex and interactive process (Appleton & Cowley, 2008). In order to accommodate for those populations that are hard to reach, there is an extension of the health needs assessment system called Health Needs Mapping. Health Needs Mapping (HNM) helps to improve and design outreach to particular populations. HNM collates information from multiple sources, linking socio-economic and lifestyle data with disease registries and GP practice as well as the incidence of illness, incorporating hospital statistics. Needs assessments can be broader than health and can include socio- economic assessment as will be in this report. The health need can be either the expectation of the population under study or the perceptions of the health care workers providing the care for that population.  Here we will use framework used for conducting HNAs is the Stevens and Raftery model which can follows an Epidemiologic, Comparative and Corporate HNA framework (Stevens and Gillam, 1998). Needs assessment generally have some fundamental approaches, such as defining a problem, epidemiological needs assessment, comparative needs assessment, study of current service provision, corporate needs assessment (stakeholder views), Identification of unmet needs and recommendations for change (NICE- Health Needs Assessment, a practical guide, 2005.)
There are three main approaches involved in undertaking this HNA- these can be comparative, corporate and/or epidemiologically based. The comparative approach compares the levels of services provided between populations, accounting for local population characteristics such as demographics, mortality and morbidity. The corporate component of the HNA focuses on demands, wishes and perspectives of the professionals, alongside the political and public views.  Encouraged by the 1989 reforms, it emphasises the importance of the public voice and forming partnerships and collaborations that support more involvement from all parties. However, a disadvantage of this approach is that differences between need and demand appear blurred at times. The third approach, combines epidemiological approaches with patient’s perspectives, involving the assessment of the effectiveness and cost-effectiveness of interventions. The below sections analyse the health need under investigation here using statistics from all the three sections on HNA i.e epidemiological, comparative and corporate respectively to show a greater insight to the various HNA’s and help decide the appropriate one for this report.

EPIDEMIOLOGY
Smoking in pregnancy is not only harmful for the mother but also for the foetus; the issues around this include premature births, increased risk of asthma and respiratory disease, increased risk of stillbirths, and low birth weight (Behnke et al., 2013). The impact of exposure to smoke in the uterus can affect development throughout childhood and beyond. Research suggests that second-hand smoke can affect upon the unborn child even when the mother is a non-smoker during pregnancy ASH (Action on Smoking and Health) (Tobacco Control Health Needs Assessment for Norfolk, 2014). Smoking in pregnancy has shown to be more prevalent in women who have never worked or are routine/ manual workers, a prominent issue in Norfolk. In Norfolk, smoking in pregnancy on record is at 15.9%. This is significantly higher in comparison to England and East of England rates, both at 13.3%. Within the Norfolk districts, the rate of smoking in pregnancy is 15.3%, with the exception of Great Yarmouth 20.4% (Statistics on Smoking: England, 2013). During 2012/13 period, there were 1,316 (14.3%) women with a smoking status at the time of delivery in maternity; this is 1.9% worse than the England average (Statistics on Smoking: England, 2013); this identifies that partners need to work together to ensure that this group receive the support required to help them quit (McBride et al.,1998).
In the year 2013 and 2014 approximately 1316 women, at the time of delivery were smokers. The Stop Smoking Services helped 33% of pregnant women in Norfolk to quit smoking. All pregnant smokers should receive expertise from local authority commissioners and local stop smoking services as suggested by ASH (Action on Smoking and Health). In addition, they need intense support up until two months of post-partum. Unlike Norfolk service providers, Great Yarmouth has sufficient capacity to offer pregnant smokers intensive support to quit. Midwives are supposed to perform carbon dioxide tests to assess the pregnant women’s tobacco exposure according to The National Institute for Health and Care Excellence (NICE) guidelines. There is also a great need for consultation and referral to stop smoking services for women whose tests highlight them as a smoker or a recent quitter. In Norfolk, this midwives operation is termed as BabyClear; NICE guidelines aim to reduce the pregnant smoker’s percentage down to 11% (Healthy Lives, Healthy People; Department of Health, 2011).

COMPARATIVE NEEDS ASSESSMENT
The national guidance derived by NICE obtained that the most effective tobacco control strategy should involve a comprehensive approach, which covers all aspects- both nationally and locally. In the past few years, UK has seen a number of new legislations geared towards establishing smoking policies. One such legislation is the introduction of Children and Families Bill, introduced in 2014, which deems it an offence for not preventing smoking while driving a private vehicle in the presence of a child. On 10^th February 2014, this bill passed by receiving a majority in the House of Lords (Tobacco Control Health Needs Assessment for Norfolk, 2014). In 2013 NICE introduced recommendations for a policy named Tobacco Harm reduction under which it advised to raise awareness regarding products containing nicotine as substitutes and spreading awareness regarding passive smoking. Awareness through self-help material about such substitute nicotine product is necessary in pregnant women trying to quit smoking; nicotine patches are a step towards a harm reduction approach for addicts. Behavioural support is also important to educate clients in understanding their smoking history; temporary quitters should follow up appointments. Lastly, the guidelines recommended the introduction of national centre of smoking cessation and training assessment for all practitioners who deal with smokers (Health Needs Assessment, a practical guide, 2005).
This section compares the recommendations provided in the NICE guidelines to the Norfolk services namely, NCH&C (Norfolk Community Health Care) and ECCH (East Coast Community Healthcare). The Tobacco Control Alliance has a shared objective to reduce smoking prevalence and affect other strands of tobacco control- for example making tobacco less affordable and tobacco regulation. According to the NICE Guidance Recommendations, Smoking cessation in secondary care such as acute, maternity and mental health services, intensive support should be present for individuals using maternity services. ECCH Norfolk introduced an opt-out rather than opt in for referrals from maternity services for pregnant women. This makes it more efficient then to have it optional. Further, they also encourage re-engagement back to their services through the Midwives if a client stops attending or do not engage with their services. To encourage such attempts, practitioners attending scan and antenatal clinics should receive relevant and up to date education. ECCH encourages the midwives to re-examine the CO readings for patients who might be at risk of resuming their smoking habits. ECCH also recommends checking and documenting the smoking status of clients during admission and delivery. Further, the availability of nicotine replacement therapy in the ward is recommended, providing more training to perform CO readings, providing advice and training while explaining the harmful effects of smoking on children; ECCH also recommends a specialist lead who can assist pregnant smokers. Similarly, the NCH&C recommends, checking the smoking status via CO testing in pregnant patients by trained midwives. Patients get continued therapeutic support along with their necessary medical treatments (Tobacco Control Health Needs Assessment for Norfolk, 2014). Although these recommendations are good theoretically, there needs to be an assessment body, which checks the implementation of these policies.

CORPORATE NEEDS ASSESSMENT

The Norfolk County Councils developed a survey termed “Your Voice” in July 2014. This survey was a means to understand the perception of the practitioners concerning Stop Smoking Services and to gain an insight about finding out the triggers which affect the smoking patients starting and stopping such habits, and to find the ideal place and time for these services. The survey took place with complete confidentiality as it only took the first part of the participant’s postcode. The results of the completed survey in which 6000 members participated are as follows. Peer pressure, smoking members in a family, joining the army and the use of smoking as a stress relief were some of the main triggers for starting smoking according to the survey results. The survey also found a number of reasons why majority of respondents quit smoking- namely ill health, gaining awareness about the harmful effects of smoking, high cost of cigarettes, understanding the impact on others and finally pregnancy or becoming a parent. Even with all the medical advances, majority of respondents used their own willpower to quit smoking, with only one quarter of them using a smoking cessation service. These services included GP surgeries, pharmacies and Smoke free Norfolk. One quarter of respondents, used a smoking cessation service to quit within 4 weeks and around one-sixth successfully quit after 4 weeks. Those who were given medication in the form of nicotine gums found them rather ineffective and addictive (Tobacco Control Health Needs Assessment for Norfolk, 2014).

STRATEGIES TO IMPLEMENT HNA
This part of the process will direct the practitioner to establish a helpful and acceptable intervention. Literature surrounding smoking in pregnant women focusses on the effectiveness of psychosocial interventions (Chamberlain et al., 2013; Abatemarco et al., 2007; Lovato et al., 2011). For this HNA, it seems that a pilot plan for psychosocial intervention would be appropriate. In the area of Norfolk, there is currently no such intervention for the support of mothers with smoking addiction. The complexity of the various factors that affect a patient with smoking addiction and the care required can be complex, so a whole team approach is required rather than an individual one. This will ensure the care for the pregnant mothers to be successfully provided. When considering the health needs intervention, a team will be required to lead it; ideally the team would consist of the health visitor, G.P.s, nursery nurses and a community mental health nurse. It is very important to have a shared vision, an understanding of various roles within the team, a respected leader, a sound action plan, flexibility, and the ability to work collaboratively are all necessary for the intervention to be successful. Contrary to concerns regarding psychosocial interventions that women may be upset by offering support to stop smoking, it is found that women expect and appreciate the support, and interventions are more likely to improve women’s psychological wellbeing than worsen it. Qualitative evidence suggests this support should be positive, not negative (Bond et al., 2012) and that the support should be sensitive to potential feelings of guilt and worry, and concerns about the impact of quitting on women’s lives and their relationship with significant others. The intervention can help healthcare providers to become aware of any of their own biases against mothers who smoke. Once the team is formed, a venue would be decided for the intervention group. The paediatrics department of all the hospitals will be an ideal venue for this. Women with smoking addictions will be referred to the group and during a home visit, information will be provided so the mothers can decide the timings suitable for them to come. It is worth noting that pregnancy is a good window for implementing cessation practices because mothers are more likely to do it for the benefit of their offspring.
Evidence suggests that just educating the patients with addiction along with risk advice is not sufficient, and any psychosocial support should include multiple or tailored intervention components that provide help with strategies to quit, positive encouragement and other strategies, such as incentives, feedback or peer support. With the potential to improve psychological wellbeing, interventions that include psychological support for women with symptoms can be highly effective. Studies show that many women resume smoking after pregnancy; consideration should be given to messages that reinforce the benefits for the mother, rather than solely focusing on benefits for the infant (Chamberlain et al., 2013). The intervention would run for 4 weeks after the first detection of smoking in a patient and the intervention group would be trained properly to conduct the intervention. Implementing some sort of exercise regime can also be helpful as the mothers can understand the importance in a natural birth and also see the effects of reduced smoking in their general cardiovascular health. Massages to reduce stress hormones that trigger the need to smoke can be very helpful and may be included in the interventions. Evaluation is also very important to understand the impact of needs assessment and to evaluate the intervention needs to be considered (Tobi, 2016). Regular checks of CO by midwives will be helpful in evaluating the effectiveness of the intervention.

CONCLUSIONS
To conclude, it may be obtained that by working through the stages of a health needs assessment, the need for an intervention in the author’s area was clearly identified. The reviews and data provided information to assist with the understanding of smoking and its harmful effects on pregnant mothers and their offspring. There is clearly a need for a more accurate and consistent way of identifying pregnant mothers who are smokers and then in recording and using the data. For the interventions to be effective, it was identified that good collaborative working was essential. As the role of the health practitioners has changed over the years, it is important to demonstrate how they may improve health services and reduce inequalities through successful, quality interventions.

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