The focus of this study was on the protection of children from tobacco smoke exposure by using a bundle of evidence based actions in an improvement project. The main result is that there are some indications of decreased ETS exposure for children in the families who had CHC nurses who participated in the improvement project. Of the families in the intervention 69% succeeded in their ambitions to increase the protection of their child/children from ETS exposure in different ways with the support from CHC nurses. In addition, one third of the nurses reported successful results overall in their area, compared to results on a national level.
One central component in the bundle was the SiCET questionnaire. It seems to provide a helpful basis for dialogue with parents who are smokers . One of the questions in the SICET which addresses parents’ willingness to change their behaviour in order to protect their child from ETS exposure was the starting point for the dialogue. The answers to this question provide nurses an opportunity to use MI to discuss changes in smoking behaviour. The use of MI as an approach in dialogue with parents gives nurses the possibility to reinforce change talk and has been advocated in conversations about changing life habits [32, 46] and has been shown to be effective in supporting smoking cessation . The CHC nurses in this study supported the parents’ belief in themselves by showing confidence in their ability to carry out the changes they wished to make.
In order to customize interventions to better fit the needs of different groups, a bundle of actions was compiled in this intervention, instead of conducting further tests of one evidence-based intervention at a time . A further reduction in smoking among parents in Sweden has been difficult to achieve especially among some groups in the population . There are still barriers to overcome. Blackburn et al.  reported, in their cross-sectional survey of UK families that even if 86% of the families knew the adverse health effects of ETS exposure in children, over 80% of these families continued to smoke in their homes. Qualitative studies have shown that the reason why disadvantaged mothers continued to smoke in the home was that they have to deal with the tension between ‘coping’ and ‘caring’ [47, 48]. In this study, 69% of the families which participated in the intervention succeeded in their ambitions to increase the protection of their child/children from ETS exposure in different ways; by changing smoking behaviour, smoking less or quitting smoking.
In the group of successful nurses (30%) the reduction of smokers in the families when child was 8 months old, 8%, can be compared to the figures for the county as a whole where the reduction was low during the same period i.e. from 15.5% in 2009 to 14.6% in 2011. No reduction of smoking in families with children aged 8 months was found in the country as a whole. Corresponding figure for the whole country were 13.7 and 13.6 during the same period (Table 5). The latter results were based on the CHC’s annual data from the National Board of Health and Welfare’s report in 2012. The findings are in accordance with other studies which demonstrate the importance of helping parents to develop strategies other than smoking cessation to protect children from ETS exposure in their homes . For example, a community-based intervention study from Portugal on how to make homes smoke-free showed a 10% decrease in ETS exposure in primary school children . The British community-based intervention ‘smoke-free homes’ delivered through schools, health care settings and community events increased smoke-free homes from 35% to 68%, six months after the intervention in an area with low socio-economic status. The study was based on self-reporting. The improvements were gained despite that no parent reported that they quit smoking . The results in this study, both from self-reports and to some extent cotinine levels in urine, indicate that nurses’ actions have influenced parents and their willingness and ability to make changes in order to protect their child from ETS exposure even if they are not motivated to quit smoking, findings which are in concordance with other studies [1, 2].
All of the ten participating parents who quit smoking had expressed willingness to change their behaviour for the sake of their children in the beginning of the study. Eight quit with the only support from the CHC nurses, thus without any support from smoking cessation professionals. The nurses’ use of MI in combination with the SiCET may have provided the necessary support for the parents’ self-efficacy by helping them believe in themselves and become confident enough to quit smoking .
Providing nurses with the ability to refer parents to a certified tobacco treatment specialist was made in order to make it possible for them to focus on assisting parents in creating smoke-free practices for the home, without spending time on the quitting process. The possibility for the nurses to primarily focus on parents in their ambitions also strengthened the parents to protect their child from ETS exposure when smoking friends and relatives visited their homes.
The SiCET is a questionnaire which provides a comprehensive picture of the child’s ETS exposure . Although the questionnaire is self-reported, it intends to be a support in the dialogue with the parents. The SiCET was used in combination with tests of children’s cotinine levels in urine. Parents have been shown to have a positive attitude to the cotinine tests during the child’s health care visits, whether if they were smokers or not . In this study, urine samples were analysed and compared before and after the intervention to demonstrate to the parents if their behaviour changes could be seen through this objective measurement of their child’s ETS exposure. The results of urine cotinine analyses in combination with the SiCET gave the nurses a possibility to have a more detailed dialogue with the parents especially in cases where cotinine values were inconsistent with the answers in the SiCET. One finding in such a dialogue was high cotinine levels in breast-fed children whose mothers smoked. This finding is in accordance with other studies showing five to ten times higher concentrations of cotinine among breast-fed children of smoking mothers compared to bottle fed children .
According to Swedish standard practice for CHC nurses, home visits to families with a new-born are recommended. This study showed that nurses primarily visited families in their homes when the child was new-born. Home visits have a preventive effect in families where children are at risk of poor social home conditions which may affect their health in a negative way . An international comparison has shown that well-child care in Denmark and in England have a stronger emphasis on home-visits in their system . The need of more selective actions among families with special needs besides the general approach has been pointed out in a Swedish study . More frequent home visits to socially disadvantaged families might contribute to more successful tobacco prevention.
The positive results of protecting children from tobacco smoke achieved in this study cannot be attributed to one single intervention, but rather the combination of the interventions in the bundle. The mode of implementation and testing of the intervention bundle through collaborative learning has been shown effective in other quality improvement projects [26, 27]. The educational activities of the nurses were combined with actions that have been shown to increase chances for sustainable improvements . However, even if positive effects were shown, there was a large variation in the adherence to the bundle between different CHCs and individual nurses. All nurses used the SiCET but other activities in the bundle were used to a varying extent and are not yet provided in a systematic way. The model for improvement thus needs to be further developed and evaluated in order to enhance further improvement and sustainability of the results. A recently presented coaching model for improvement teams may be one helpful addition [Godfrey MM, Andersson-Gare B, Nelson EC, Nilsson M, Ahlstrom G: Coaching interprofessional teams in health care improvement, submitted].
Although the collaborative learning sessions had one of its focus on reaching foreign born parents, the nurses in this study used MI less often to this group of parents than to Swedish born parents. One reason could be linguistic problems but not the only . Few nurses used interpreters in dialogue with parents, and some parents chose not to have interpreters involved when offered. Migrants’ perception of using interpreters in health care is that they can be impeding in terms of insecure literal translation, create a feeling of dependency, and uncertainty about confidentiality . On the other hand, interpreters can facilitate communication if they work as communication aids and are respectful, keeping the code of confidentiality and have a professional attitude . Interpreters in health care have proven to be underused and dependent on the individual health-care practitioner’s own initiative and knowledge according to other studies . Subtleties in language mean that an interpreter is needed to limit misunderstandings and are thus crucial to maintain a high standard of health care [59, 60]. To our knowledge there are no studies using MI through interpreters. A further opportunity for improvement would thus be a study in how to more systematically use interpreters in combination with MI.
Further, the foreign born parents were not provided with booklets to the same extent as Swedish-born parents, despite that they were available in all the languages used by participating parents in the study. A previous study showed that parents want to have and read information concerning children and their health  and migrants want written information both in Swedish and in their native language . Thus booklets written in parents’ native languages may help assist them in their decision to change their smoking behaviour. In addition, parents could use the information to inform relatives and friends as it has been shown that even if parents are non-smokers, grandparents may be smokers and need to be informed on how to protect their grandchildren from ETS exposure . Why nurses did not use this opportunity equally with all participants was not part of this study. More studies are needed to understand how to reinforce the use of the bundle of interventions in order to also reach foreign born parents.
Future larger evaluative studies, carried out in different contexts can be helpful in providing more knowledge on which combinations of interventions are most efficient in different circumstances . The impact of using the collaborative learning approach in this kind of intervention also needs to be further explored with in depth qualitative studies. Some of the nurses seem to have been very successful in changing their traditional way of working while others, just like smoking parents seem to have more difficulties in changing their habits.
The final number of families who participated in the intervention resulted in low numbers in each sub-group which limited the opportunity to reach statistical significance in some of the analysis. Despite intense efforts, it was difficult to recruit a large number of nurses to take part in the intervention due to high workloads in the CHC areas. More nurses would most likely have been able to recruit more parents to the project. Furthermore, the nurses’ engagement and use of the suggested actions also had a role in the results which was evident from differences in the amount of data in the log-books. The agreed actions were not used systematically by the nurses among all parents. An evaluation of the nurses’ changed behaviour would have been interesting and important, but the methodology used in this intervention was not designed for this purpose.
The short follow-up period is a limitation in the study as sustainability of smoking cessation needs to be followed over time. Another limitation is the lack of a control group, but the positive change over time, before and after the improvement project regarding children’s ETS exposure in the studied areas, also in relation to the county and the country as a whole, indicates a positive effect. Further comparisons will be provided with matched control areas from another county in a larger future study.