A cross-sectional survey of the prevalence of environmental tobacco smoke preventive care provision by child health services in Australia

Children are particularly vulnerable to the harmful effects of environmental tobacco smoke (ETS) because of their relatively underdeveloped immune and pulmonary systems, their small body size, and their higher rates of ventilation [1, 2]. Exposure to ETS increases a child's risk of developing diseases of the respiratory system, otitis media and sudden infant death syndrome [1, 3, 4]. Further, child exposure to ETS is linked to increases in the frequency and severity of asthma symptoms, and both the onset of cardiovascular disease and permanent smoking behaviours in adulthood [1, 3–5]. Hence, reducing child levels of exposure to ETS is a recognised public health goal [1, 5].

Given that child exposure to ETS is most commonly associated with smoking by parents and other household member [6–8], interventions to reduce child levels of exposure have focused on encouraging parental smoking cessation and modifying parental smoking behaviours within the family home [9–11]. Such interventions have resulted in significant reductions in child levels of exposure to ETS [1, 5, 9]. Despite such reductions, a significant proportion of children continue to be exposed to ETS [1, 4, 6, 12], and continued efforts to reduce childhood exposure to ETS are required [1, 2, 5, 6].

Health facilities present an ideal opportunity to deliver ETS-prevention advice to parents [11]. First, they have the potential to reach up to 99% of parents of both well and sick children [13, 14]. Second, research suggests that parents of well and sick children are receptive to ETS-prevention care delivered within health care settings [11]. Third, ETS-prevention interventions when delivered by health care professionals have been demonstrated to be efficacious [15–18]. Finally, the implementation of ETS-prevention care within health facilities is consistent with clinical best practice care delivery policies and guidelines [15, 19, 20].

Limited international evidence provides an insight into the level of ETS prevention care routinely provided in child health care settings. Such evidence is primarily United States based and addresses care provided by physicians only [14, 21–23]. It suggests that health care professionals fail to routinely assess the ETS exposure of children, and to provide parents with advice on how to reduce child exposure to ETS [21, 23, 24]. Health care professionals cite a number of barriers to the provision of smoking cessation and other ETS-prevention related care, including a lack of time, skill and organisational support [11, 21, 23, 25]. However, various strategies such as written policies, training, and reminder systems have been shown to be efficacious in facilitating clinical practice change generally, the provision of preventive care generally [26, 27], and the provision of ETS preventive care specifically [21, 28].

To date, research describing the provision of ETS-prevention care by heath care professionals, and the prevalence of strategies to support such care is limited. Given this, a study was undertaken to determine the: prevalence of ETS preventive care in child health services; the differences in care provision by type of child health services; the prevalence of strategies to support such care; and the association between care support strategies and care provision.

This study is the first that reports the prevalence of ETS preventive care routinely delivered by Australian public child health services. We found that a large proportion of such services failed to routinely assess ETS risks or provide ETS exposure prevention advice to parents of attending children. The results also suggest the limited existence of clinical practice strategies to support the provision of such care. The results indicate a considerable need and potential for additional clinical practice initiatives to realise the benefits of ETS prevention care for children.

The results of this study, despite methodological differences, are consistent with those of research in other countries that suggest that approximately half of child health services fail to assess the smoking status of the majority of parents [14, 21, 23, 25]. For example, Winickoff et al surveyed 902 parents regarding the level of ETS prevention care provided by their family physician or paediatrician and found that 51% of parents reported being asked about the smoking status of household members [21]. Although the assessment of children's ETS exposure was found to occur at a lower level in the current study (14% of services routinely assessed ETS exposure), the observed level supports the findings of previous research that such assessment occurs at an inadequate level [21, 25].

The results of the current study suggest that most services fail to routinely provide smoking cessation and ETS reduction advice to parents, which is consistent with previous research [14, 21, 23, 25]. However, the current study's findings that 28% of services routinely provide smoking cessation advice to parents is lower than that reported previously [14, 21, 23, 25]. In the study described above, Winickoff et al found 40% of parent smokers were advised to quit [21]. The current study's findings that 46% of services provided ETS exposure reduction advice to parents of children at risk is also consistent with previous studies [21, 25].

The results of this study extend previous research by examining and demonstrating differences in the prevalence of ETS prevention care between types of services and clinicians [22, 23]. The current study found that community-based child and family health services were more likely to assess both types of ETS risk. Similarly, community-based child and family health services, and Peer Group 2 hospital, more commonly provided parental smoking advice compared to Peer Group 1 hospitals, and community-based child and family health services were more likely to provide ETS reduction advice. Generally, the higher prevalence of care delivery in community-based child and family health services may be explained by their focus on 'well child' assessments and care, in comparison to the more acute clinical focus of hospitals [32]. The variability in care delivery between care settings suggests that a greater understanding of the differences in values, policies, systems and care delivery contexts between settings is required in order to facilitate the development of appropriately tailored interventions.

Evidence suggests that intervention strategies that are most effective in increasing ETS prevention care are system level strategies such as policies [33], reminder strategies or multi-component approaches inclusive of reminders and education [28]. The evidence suggests that multi-strategic approaches are more likely to be successful as they address the known multi-dimensional nature of barriers to the provision of such care [34]. Multi-strategic intervention approaches are also supported by review evidence regarding the provision of smoking cessation care [15, 35], and changing clinical practice more generally [36, 37].

The findings of this study support such previous research, by suggesting that where clinical practice is supported by a written policy, training and care prompts, clinicians are more likely to assess children's ETS risk and provide ETS prevention care. Despite this positive finding, it is evident that the majority of child health services do not incorporate support strategies within their organisations. Training regarding ETS prevention care was the most often reported support mechanism (47%) followed by ETS care prompts (20%), the existence of a policy outlining the provision of smoking cessation care (22%), and policy outlining ETS reduction care (12%). Such outcomes are similar to those reported in the adult inpatient setting [29].

The observed low levels of organisational support can be argued to have contributed to the finding that the majority of children attending child health services are not being assessed for ETS risk, or provided ETS prevention care. As these findings occur in the context of international and national guidelines that mandate the provision of ETS prevention interventions [15, 38], the findings suggest additional initiatives to enhance the provision of these forms of care are required.

The findings of this study should be considered in the context of a number of its methodological characteristics. First, the study relied on the use of an indirect estimate of care prevalence by utilising self-report data of senior unit managers. Results obtained from self-report studies can be confounded as respondents commonly over-report the routine provision of assessment and advice [39]. If this was the case, the observed low frequency of reported provision of ETS prevention care represents an over estimation of actual practice, strengthening the conclusion that further care support initiatives are required. Given the limitations of both direct and proxy measures of clinical practice, further research should consider the use of a triangulation of multiple data collection methods [40]. Secondly, in some instances there were small frequencies in some cells for analysis and therefore conclusions regarding predictors of care should be considered exploratory. Finally, care should be taken when generalising these finding to child health services outside of Australia because of the unknown impact of differing child health service structures

There is a clear need to further enhance the provision of ETS prevention care in child health services. Considering the documented efficacy of care support strategies such as reminders, education and policy, the further dissemination of ETS preventive care guidelines should incorporate such strategies.

This study was undertaken with the support of Hunter New England Population Health and infrastructure support from the Hunter Medical Research Institute.

The sources of funding for the study, for each author, are as follows:

TH: Hunter New England Population Health, New South Wales (NSW) Department of Health, Australia; Faculty of Psychology, The University of Newcastle, NSW, Australia; Hunter Medical Research Institute, NSW Australia.

JD: Hunter New England Population Health, New South Wales (NSW) Department of Health, Australia; Faculty of Health, The University of Newcastle, NSW, Australia; Hunter Medical Research Institute, NSW Australia.

JB: Faculty of Health, The University of Newcastle, NSW, Australia; Hunter Medical Research Institute, NSW Australia.

MF: Hunter New England Population Health, New South Wales (NSW) Department of Health, Australia; the Faculty of Health, The University of Newcastle, NSW, Australia; Newcastle Institute of Public Health, NSW Australia; Hunter Medical Research Institute, NSW Australia.

JW: Hunter New England Population Health, New South Wales (NSW) Department of Health, Australia; Faculty of Health, The University of Newcastle, NSW, Australia; Newcastle Institute of Public Health, NSW Australia; Hunter Medical Research Institute, NSW Australia.