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Corresponding author: Dr Kimberly Horn, PO Box 9190, Morgantown, WV 26506 (e-mail: khorn{at}hsc.wvu.edu).
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Abstract |
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Objectives To determine the reach, implementation fidelity, and acceptability of a brief motivational tobacco intervention for teens who had treatment in a hospital emergency department.
Methods Among 74 teens 14 to 19 years old, 40 received a brief motivational tobacco intervention and 34 received brief advice/care as usual at baseline. Follow-up data were collected from the interventional group at 1, 3, and 6 months and from the control group at 6 months. For the interventional group, data also were collected from the teens’ parents, the health care personnel who provided the intervention, and emergency department personnel.
Results Findings indicated low levels of reach, high levels of implementation fidelity, and high levels of acceptability for teen patients, their parents, and emergency department personnel. Data suggest that practitioners can operationalize motivational interventions as planned in a clinical setting and that patients and others with an interest in the outcomes may find the interventions acceptable. However, issues of reach may hinder use of the intervention among teens in clinical settings.
Conclusions Further investigation is needed on mechanisms to reduce barriers to participation, especially barriers related to patient acuity.
Since its development, motivational interviewing has been adapted for brief encounters in a variety of health care settings for numerous problem behaviors among adolescents and adults.5,6 For instance, recent studies3,7–10 indicated that brief, tailored interventions with motivational interviewing are at least as effective as other treatment methods for mild-to-moderate alcohol problems and are clearly superior to no treatment.
Some research7,11 suggests that these motivational techniques also may be useful for smoking cessation among teenagers. Because motivational interviewing occurs in a single "on the spot" intervention (usually <30 minutes), many experts suggest that it supports a population health approach to reach large numbers of teen smokers without the resource demands of multisession interventions. Moreover, and particularly important for teens, motivational interviewing may be acceptable to teens "because of its brief duration, nonconfrontational and empathic therapist style."11
| Motivational interviewing is a common, brief technique used to facilitate smoking cessation.
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Together, these factors suggest that clinic-based brief interventions with motivational interviewing may be a feasible method to promote smoking cessation or reduction among teens. Yet few investigators12 have examined the overall feasibility of using clinic-based motivational strategies to change behaviors among teens, particularly in the settings for which these methods are most recommended (ie, hospital clinics and emergency departments). The lack of feasibility assessment has critical implications, because interventions for which implementation is unfeasible are not likely to be widely adopted, even if the interventions are effective.
A better understanding of the feasibility of a clinic-based teen smoking cessation with motivational interviewing requires that researchers go beyond conventional evaluations that focus solely on efficacy. Glasgow et al argue for broader evaluation strategies and eloquently point out that the "efficacy-based research paradigm that dominates our current notions of science is limiting and not always the appropriate standard to apply."13(p9)
Feasibility can be assessed by answering questions such as the following14: How much does it cost? What are the time requirements? Does it require staff training? Do we have access to the target population? How much space will we need? Do we have the necessary equipment? Can we access program materials? Does the program require any additional services (eg, transportation)? Moreover, feasibility must address critical factors of patient reach, patient and practitioner acceptability, and ease of implementation13 (see following list for definitions). Researchers must understand these factors before recommending motivational strategies for widespread dissemination in the hectic, often understaffed clinical environment.
As part of a larger evaluation study,15 we examined the feasibility of implementing a brief motivational tobacco intervention (MTI) for teens who had treatment in the emergency department at Ruby Memorial Hospital, Morgantown, West Virginia. We assessed feasibility on the basis of 3 factors13:
We hypothesized that the MTI would reach at least 75% of age-eligible smokers who came to the emergency department for care, be implemented as prescribed, and be acceptable to patients, patients’ parents, providers, and other emergency department staff.
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Methods |
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Data were collected from teens at baseline (immediately before implementation of the MTI) and 1, 3, and 6 months later. Parents of the participants were interviewed and completed a questionnaire at baseline. MTI providers recorded essential fidelity information (ie, the extent to which the MTI was delivered as planned) immediately after each interview with a teen participant. Emergency department staff completed a questionnaire approximately 6 months after the onset of the study. Nonphysician staff were interviewed because they were the ones most likely to interact with the participants in the MTI program and its providers.
Procedure
A blinded, randomized 2-group design was used. Teens were divided into 2 different groups: one group received the MTI; the other received brief advice/care as usual (BA). The MTI consisted of (1) screening; (2) a 15- to 30-minute face-to-face motivational interview tailored to the patient: readiness assessment, reflection on smoking behaviors, and a general health inventory; (3) a stage-matched, self-help workbook with audio (called the Power Guide); (4) a handwritten personal postcard within 3 days of the visit to the emergency department; and (5) 3 follow-up "booster" telephone calls at 1, 3, and 6 months after the visit to the emergency department.
BA consisted of (1) screening; (2) 2 minutes or less of generic advice to quit smoking; (3) referral to 1-800 Health Line, a general information source; and (3) a follow-up phone call 6 months after the visit to the emergency department.
Trained providers were located in the emergency department during the busiest periods (noon-midnight) for intake of patients. Providers had relevant backgrounds in social work, psychology, and public health education and received approximately 75 hours of on-site training in motivational interviewing, the study protocol, and all relevant study forms. Training also included role-playing, hands-on practice, and direct observation by us in the emergency department.
A highly prescribed, blinded randomization procedure was used. Specifically, all required study forms were collated into folders for the MTI and BA intervention groups, then combined in a single stack in random order as generated by the SAS random number function (SAS Institute Inc, Cary, North Carolina). Each randomized manila folder contained either the MTI or the BA forms and instruments required for implementation with a teen patient. The stack had equal numbers of MTI and BA folders of equal weight and size. Each provider took a folder from the stack (located in a secure location in the emergency department) before approaching a patient. The provider had no knowledge of the contents of the folder and did not know the patient’s group assignment until the folder was opened. For additional details, see Horn et al15 and Hungerford et al.16
| On average, teens smoked half a pack of cigarettes per day.
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Data Collection
Reach.
Reach was determined by using the following variables: total number of age-eligible patients during all shifts; total number of age-eligible patients available during the MTI shift coverage; total number of age-eligible patients approached who were current smokers; and total number of age-eligible smokers who assented and consented, withdrew, and complied through follow-up. Several sources were used to assess reach, including the emergency department–based injury surveillance system (EDBISS). EDBISS, the hospital’s central database, provided data on the total number of 14- to 19-year-old patients who came to the emergency department during the study period and on the number in this age group who sought treatment during the MTI shift coverage (Monday through Sunday, noon through midnight). Providers’ approach forms offered data on the number of patients approached who were current smokers and the number who assented or consented to participate in the study.
Follow-up forms were used to collect data by telephone from MTI patients at 1, 3, and 6 months after baseline. Teens in the BA group were contacted only once, 6 months after their visit to the emergency department. The follow-up forms also were used to document participants’ smoking status16 (eg, How many days in the past month did you smoke a cigarette?).
Implementation Fidelity. Implementation fidelity was determined solely for the MTI group. Data were obtained from the follow-up forms and from the MTI provider assessment forms. The 18-item provider assessment forms were used to obtain each provider’s perceptions of his or her interaction with each MTI patient. The provider assessment form documented the essential elements of the intervention protocols: (1) the MTI providers’ perceptions of a patient’s "stage of change," rated from 1 (do not plan to quit smoking in the next 6 months) to 4 (have made a serious attempt to quit in the past 6 months); (2) intervention topics and other issues covered; (3) referrals made for additional assistance; (4) useful or nonuseful strategies; (5) contextual issues, such as where the interview took place, presence of others; (6) cooperation of teen patients, their parents, and emergency department staff; (7) comfort level of the MTI provider; (8) MTI providers’ perceptions of inaccuracies in teen patients’ responses; and (9) goal setting by teen patients. To facilitate recall accuracy, providers completed this form immediately after each teen patient intervention. In order to ascertain the amount of time spent with each teen, a shift summary was used to document the time each shift began and ended, day of the week, date, and provider name for any given project shift.
| The smoking rate in the target population was 30.7%, which was lower than anticipated.
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Acceptability. Teen participants, their parents, and emergency department staff assessed acceptability. Data were recorded on a variety of forms, including specific items on the teen follow-up forms described earlier, the emergency department personnel questionnaire, and the parent/guardian information form. The emergency department personnel questionnaire was an 11-item questionnaire used to assess agreement among emergency department staff. Each item was rated on a 5-point Likert scale ranging from 1 (strongly agree) to 5 (strongly disagree). Questions addressed perceptions of the MTI project, interactions with MTI providers, MTI acceptability in the emergency department, and need and support for the MTI project. This questionnaire was administered during a single shift (3 PM–11 PM) early in year 2 of the trial.
The parent/guardian information form was a 9-item form that included basic demographic information about patients’ parents, the parents’ attitudes toward smoking, levels of support for the teen patients’ efforts to quit smoking, and attitude toward emergency department–based smoking intervention. MTI providers administered this form to parents at baseline, before teen patients received the intervention.
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Results |
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). Mean age was 17.8 years (SD, 1.12). Teens smoked one-half of a package of cigarettes daily (mean, 9.91 cigarettes; SD, 7.98; Table 1).
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The 10 MTI providers were trained adult professionals with no less than a bachelor’s degree in a range of disciplines, including social work, public health, and psychology; 8 of the providers (80%) were women. MTI providers were available approximately 40% of all shifts (100%=24 hours/7 days per week), with shifts primarily covering the busiest emergency department periods (eg, noon-midnight). Among the 19 available members of the emergency department staff, 10 (53%) completed the staff questionnaire. Respondents were nonphysicians, such as nurses and physician assistants.
Reach
On the basis of 1997 EDBISS data, we initially expected that 2446 age-eligible teen patients would be present in the emergency department during a 12-month period (totaling 4892 in years 2 and 3 of the trial). On the basis of data from the 1998 Youth Risk Behavior Survey, Centers for Disease Control and Prevention, we planned for a 41.9% smoking rate or 1024 teen smokers in each year (2048 total). During the study period, 6749 age-appropriate patients (14- to 18-year-olds in 2003; 14- to 19-year-olds in 2004) came to the emergency department for treatment, a number higher than our original projection of 4892 teens (see Figure
).
Approximately 2699 age-eligible teens were present during shift coverage. Critically important, the Health Insurance Portability and Accountability Act went into effect during the study. These new regulations made it impossible to track reasons for nonapproach of all age-eligible patients. Therefore, only estimates of the total eligible youth were available from EDBISS.
Among 2699 age-appropriate teens available during shift coverage, providers approached or reached 896 (33.2%). If overall reach is calculated on the basis of 6749, the total number of possible age-appropriate youth within and beyond our shift coverage, the reach is 13.3%. Precisely 59 teens were outside the age requirements, had already been approached in a previous visit, or had no guardian with them; thus, the overall smoking rate was calculated on the basis of 841 teens. Among those teens, 579 reported that they were not smokers. We classified the remaining 258 teens as smokers, for a smoking rate of 30.7% in the targeted patients.
Of note, the smoking rate in the target population (West Virginia teen smokers in the emergency department) was lower than we anticipated (30.7% vs 41.9%; between 1998 and 2004, the teen smoking rate in West Virginia decreased from 41.9% to 24%). If the 30.7% smoking rate in the targeted patients is applied to the total 6749 age-eligible teens and the 2699 approached during our shift coverage, the number of eligible teen smokers was approximately 2071 overall and 828 during shift coverage. As a bottom-line estimate, we reached approximately 6.2% (128 of 2071) of the total smokers in our population overall and 15.5% (128 of 828) during the shift periods covered by our providers.
A total of 128 of the 896 teens approached (14%) were eligible to participate in the study. Among the 52 who chose not to participate, the most frequently cited reason for refusal was acuity or severity of condition (54%); approximately one-third of patients offered no reason for refusal (33%). Precisely 76 of 128 teens (59.4%) consented to be in the study. One participant was discharged before finishing the assessment, bringing the sample to 75. Among those 75 patients, 1 patient withdrew after the MTI assessment; the reported reason was acuity.
At 1, 3, and 6 months, 11 of 40 (28%), 17 of 40 (42%), and 28 of 74 (38%) teen participants were available, respectively. An attrition analysis was conducted to detect any baseline differences between teens who provided 6-month follow-up data and those who did not. A 2 (present/absent) x 2 (MTI/BA) multivariate analysis of variance of number of cigarettes smoked on weekdays and weekends, nicotine dependence, age, and previous attempts to quit smoking revealed no significant differences between teens who did or did not (present/absent) provide data at 6-month follow-up. The quit outcomes are discussed extensively elsewhere.16 In summary, among the 74 participants, 2 quit smoking, 1 teen in each treatment group at 6-month follow up. Cessation rates were not significant. However, a medium effect size (Cohen’s h = .38) was found for reduction in smoking and a large effect for percent reduction (Cohen’s h = .69).
Implementation Fidelity
Fidelity was assessed by determining if the MTI was delivered as planned in the emergency department. As recommended by Miller and Mount,17 analysis for intervention assessment and fidelity was based on 1-time data collection from providers after each MTI intervention with a patient. Descriptive frequency analysis was applied. As intended, MTI patients received a higher dosage of provider contact/intervention in the emergency department than did the BA patients (20.45 minutes vs 2.03 minutes; Table 2). When all patient contact from baseline to follow-up was factored in, MTI patients received a mean of 30.6 minutes of contact compared with 11.86 minutes for BA patients.
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).
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Providers were required to give each MTI patient the Power Guide workbook before the patient left the emergency department. The workbooks were given to teens as planned. Of the 16 patients in the MTI group who participated in the 6-month follow-up, 56% (9 patients) reported using the workbook (Table 4) and 78% (7 patients) reported that it helped them change their smoking behavior. Half of the patients who reported quitting or reduced smoking used the workbook. However, no significant relationships were detected between workbook usage and changes in smoking behavior.
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).
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). Of the 10 respondents, 9 reported that they were adequately informed about the project.
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). However, parents were overwhelmingly supportive of both MTI and youth participants’ desire to stop smoking. A total of 12 parents (92%) believed that the emergency department was an appropriate place for a teen smoking intervention. In addition, 6 parent smokers (46%) were responsive to receiving cessation information for themselves.
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Discussion |
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On the basis of previous studies on smoking cessation in teens, we predicted that about 75% of the eligible smokers would consent to participate in the study; our actual consent rate was 59%. The lower-than-predicted consent rate has several possible explanations. First, the initial study projections were based on the assumption of a 41.9% smoking rate among teens in West Virginia, which was the rate at the time of study preparation. The teen smoking rate dropped significantly between 1999 and 2004, from 42% to 24%.18 The smoking rate among our age-appropriate study sample in the emergency department was about 30.7%, so fewer teen smokers were available than anticipated.
Second, we experienced higher-than-expected patient acuity. General patient acuity is defined as "the number of patients requiring emergency department resuscitation efforts and/or admission to the hospital."19 Most of the teens were approached during daylight hours, which are the busiest emergency department shifts and when high acuity is most likely.20 More important, certain types of illnesses, such as pains and infections, are highly correlated with patients’ acuity.21 Among our teen patients, pain was the most common reason for their visit to the emergency department.
Finally, two-thirds (1803 of 2699; 66.8%) of the age-appropriate youth in the emergency department during our shift coverage were not approached by the providers. Again, the primary reasons were related to patients’ acuity.
Fidelity
Exploring fidelity allowed us to determine if the intervention was delivered as planned. On the basis of the theoretical components prescribed by the motivational interviewing framework,1 data suggested that providers administered motivational strategies as trained. Consistent with state-of-the-art recommendations,1 the providers used several methods to facilitate change in smoking behavior. Results from the provider assessments suggest that providers administered the required MTI components. Providers covered a variety of topics; the most common were confidence, physical consequences of smoking, and reasons for quitting. However, despite providers’ perceptions that patients moved along the stages of change from contemplation to preparation, actual patient data indicated that patients remained in the contemplation stage throughout the study. A majority of patients in the MTI group reported that they used the Power Guide workbook. Of note, MTI patients showed significant increases in recognizing the importance of quitting. During the intervention, as perceived by the MTI providers, 17 of 40 teens (42%) set a goal to stop or cut back on smoking. This finding suggests that the discussion of relevant MTI topics achieved its intended goal in almost half of the patients.
| Teens given the motivational tobacco intervention showed higher awareness about the importance of smoking cessation at follow-up.
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Acceptability
All teen patients who provided follow-up data agreed that the MTI approach was a helpful one for smoking cessation. Most (82%) reported learning new information, and all agreed or strongly agreed that the emergency department is a good place to address smoking cessation in teens. At 1-month follow up, 6 of 11 MTI teens said that if they had not received a smoking intervention in the emergency department, they would not have received it at all.
Emergency department staff also supported the project. One concern before the study began was that the intervention would disrupt day-to-day operations in the emergency department. On the emergency department staff survey, 100% of respondents agreed or strongly agreed that MTI fit in well with the day-to-day emergency department flow; 100% also agreed that the MTI should continue as a routine service.
Similar support was indicated by the teens’ parents. Most parents (92%) stated that they wanted their teens to stop smoking, and 92% believed that the emergency department was as good a place as any to deliver cessation services. In addition, among the 77% of parents who also smoked, almost half were amenable to receiving information to aid their own cessation efforts.
Limitations
Several limitations should be noted. First, 96% of the study participants were white. In addition, most were from West Virginia, which is largely a rural state. Thus, caution is warranted when applying these results to nonwhite or nonrural populations. Second, our refusal rate was high. Among 128 age-eligible teens, 52 chose not to participate. Refusals were mainly due to acuity issues. As such, our sample reflects emergency department patients with minor medical conditions; such patients may be the most appropriate subpopulation for this type of cessation service. Last, our follow-up percentage was lower than anticipated. At 1, 3, and 6 months, 11 of 40 (28%), 17 of 40 (42%), and 28 of 74 (38%) teen participants, respectively, were available for follow-up, a situation that may introduce biases in favor of compliant teens. However, of note, attrition analyses showed no differences between the characteristics of teens available at baseline and those available at the critical comparison 6-month follow-up.
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Conclusion |
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In this feasibility study, we explored the reach, implementation fidelity, and acceptability of a brief MTI for teens who came to the emergency department for treatment. Our findings indicate low levels of reach, high levels of implementation fidelity, and high levels of acceptability for teen patients, their parents, and emergency department personnel. Overall, our findings suggest that motivational interventions can be operationalized as planned in a clinical setting and may be acceptable to patients and others who have an interest in the outcomes. However, despite high fidelity and acceptability, the MTI did not achieve the desired results in terms of reach and efficacy.16 Although compared with teens in the BA group, twice as many teens in the MTI group reduced smoking, the MTI teens did not quit smoking. Significant reduction rates, however, suggest the value of MTI for reducing the harm associated with smoking.
Our positive findings of implementation fidelity and acceptability must be considered in the context of treatment efficacy and reach, including the challenges of recruiting young smokers in clinical settings such as the emergency department. Sometimes interventions may be effective under controlled conditions but not feasible or acceptable in real-world clinical conditions. Other times, as in this study, interventions may be mostly feasible and acceptable but not effective in terms of complete cessation. Our findings underscore the importance of examining all facets of intervention programming. Crucial feasibility issues of reach, recruitment, and retention require in-depth investigation, especially in clinical settings where patients’ acuity must be considered.
Our findings provide several important lessons for researchers and practitioners. First, like Glasgow et al,13,14 we recommend that researchers who examine smoking cessation in teens take a comprehensive approach, exploring a range of intervention factors, including both efficacy and feasibility. This type of approach will increase understanding about the suitability of an intervention for widespread use in specific clinical settings. Different settings may pose different or unique challenges. As we found, the emergency department presents unique challenges because of the acuity of the patients. It may be necessary to administer these types of interventions among certain subgroups of teen patients with less severe signs and symptoms or conditions. Many emergency departments across the United States now have mechanisms to "fast track" nonacute patients.
Second, in contrast to other types of clinical settings, emergency departments provide time-limited patient-provider relationships. Because no established relationships exist, motivational interventions may require a tailored approach to establish trust and reach teens in emergency department settings and to retain the teens for follow-up contact.23
Finally, despite a carefully executed intervention protocol, we did not affect large numbers of teens. Protocol fidelity does not necessarily dictate high reach and high impact. Nonetheless, those who participated had positive views of the program. The study findings underscore the importance of understanding the potential barriers to the reach of the intervention before it is implemented. Before implementation, researchers and practitioners should carefully and strategically plan to address barriers to reach and recruitment that may be unique to or characteristic of a particular clinical setting.
Although the overall results of the MTI were negative in terms of quit rates, it is premature to suggest that emergency department–based motivational interventions are not effective for teen smokers. Specifically, the reduction in smoking in our efficacy study15 indicates that motivational interviewing may have some value as an approach to reduce the harm of smoking. Still, our findings may raise concerns about the appropriateness of using the emergency department for smoking interventions with teens. In previous research24,25 with adults in the same emergency department, this setting was effective for delivering a motivational intervention for alcohol problems. Unfortunately, in this study with teens, our methods did not allow us to determine whether low reach was due to the setting or to the interaction between the setting and the targeted population.
| Despite high fidelity and acceptability, this motivational tobacco intervention did not achieve expected levels of reach to subjects or efficacy.
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We also were unable to determine if the challenges faced in our study were typical of emergency department settings, arose from the particular teen population cared for in this rural emergency department, or were the function of programming in the context of research. Before the emergency department is discounted as a setting for smoking cessation in teens, additional studies should address the feasibility of an emergency department– based teen smoking intervention in multiple clinic-based settings, and under research and nonresearch conditions.26
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
This study was funded by grant 71600101 R18 from the Agency for Healthcare Research and Quality.
Now that you’ve read the article, create or contribute to an online discussion about this topic using eLetters. Just visit www.ajcconline.org and click "Respond to This Article" in either the full-text or PDF view of the article.
To learn more about tobacco cessation intervention strategies in the ICU, visit www.ajcconline.org and read the article by Heath and colleagues, "Evaluation of a Tobacco Cessation Curricular Intervention Among Acute Care Nurse Practitioner Faculty Members" (American Journal of Critical Care, May 2007).
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REFERENCES |
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This article has been cited by other articles:
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  B Neuner, E Weiss-Gerlach, P Miller, P Martus, D Hesse, and C Spies Emergency department-initiated tobacco control: a randomised controlled trial in an inner city university hospital Tob. Control, August 1, 2009; 18(4): 283 - 293. [Abstract] [Full Text] [PDF]
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 D. Hackbarth Research Reporting and Evidence of Effectiveness: Why "No Difference" Matters Am. J. Crit. Care., May 1, 2008; 17(3): 218 - 220. [Full Text] [PDF]
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