Abstract
Only half of the states in the U.S. mandate that foster homes have a smoking ban. It is beneficial to promote training about the impacts of exposure to secondhand smoke to foster caregivers. This article presents the evaluation of a training delivered to foster and adoptive parents in Georgia. The topics with highest values learned were: 5 steps to creating a smoke-free home, benefits of a smoke-free home, dangers of secondhand smoke, and thirdhand smoke.
Keywords: Foster care, secondhand smoking, smoking restrictions
Introduction
Due in large part to the remarkable progress in creating smoke-free environments in the U.S. over the past two decades, the home is now a primary source of exposure to secondhand smoke for both children and nonsmoking adults (US Department of Health and Human Services, 2006). From 1992 to 2011, the proportion of smoke-free homes increased from 43.0% to 83.0% (Centers for Disease Control and Prevention, 2009; King, Patel, & Babb, 2014). African American and low income households as well as households in which at least one person smokes are less likely to have total smoking bans (Gilpin, White, Farkas, & Pierce, 1999; Norman, Ribisl, Howard-Pitney, & Howard, 1999; King, Patel, & Babb, 2014; Homa et al., 2015). As a result, exposure to secondhand smoke remains relatively high for children and low-income families across racial and ethnic groups (Schober, Zhang, & Brody, 2008). Children and nonsmoking adults who live with a person who smokes still experience significant exposure to secondhand smoke (SHS) in the home (Pirkle, Bernert, Caudill, Sosnoff, & Pechacek, 2006; Schober et al., 2008). Chronic exposure to SHS in children is related to increased risk of lower respiratory infections (e.g., bronchitis and pneumonia), middle ear infections, severity of asthma symptoms, sudden infant death syndrome, and lung cancer later in life (California Environmental Protection Agency & Air Resources Board, 2005; US Department of Health and Human Services, 2006). Risk for adverse health effects in children increases as the number of adult smokers in the household increases (Pirkle et al., 2006).
Foster care is a state program that provides temporary homes for children whose families cannot provide a safe and nurturing environment for them. Nationally, in 2012, 397,122 children were in foster care. The mean age of the children was 9.1 (SD=8.5) and the average length of stay was 22.7 months (median = 13 months) (US Department of Health and Human Services, 2013). Foster children were roughly equal in gender (52% male) and mostly White (42%) or African American (26%) (US Department of Health and Human Services, 2013). Currently, only 22 states (44%) have an explicit policy prohibiting smoking in foster homes and/or cars (Public Health Law Center, 2013).
In Georgia, the Division of Family and Children Services (DFCS) does not prohibit smoking, but recommends against smoking. Foster children can be placed in a variety of placement types including relative homes, non-relative foster homes, adoptive homes, hospitals and group homes. From 2005 to 2010, the range of foster care children entering the system was 5,469 to 10,887 per year (Children’s Bureau, 2012). There were 4,421 foster homes and 13,795 children who were in the custody of DFCS during 2010 (Georgia Department of Human Resources, n.d.). These children were 51% male and mostly African American (47%) or White (48%). About 48% of the children in Georgia’s Division of Family and Children Services custody live in a family foster home and 18% live with relatives (Georgia Department of Human Resources, n.d.). For 2011, there were 8,515 children in DFCS custody with most placed in DFCS foster homes (33%), followed by child placing agency foster homes (23%), relative homes (15%), and child caring institutions (15%). Children are discharged from foster care for many reasons. Over 88% achieved permanent living arrangements through reunifications, placement with relatives, adoptions or guardianships. Many children who have significant special needs are placed in therapeutic institutions, hospitals or group homes.
Foster parents are required to complete annual trainings on topics related to the health and care of foster children in addition to their initial assessment and training. The National Foster Parent Association offers education and resources for parents caring for children who are out-of-home place (http://www.nfpaonline.org/). There are state and local affiliates of the NFPA which serve foster and adoptive parents locally. They provide opportunities for education through regular meetings.
Due to the lack of universal bans of smoking among children placed in foster systems, education about the dangers of secondhand smoke exposure is essential to reducing risks of SHS among children who are wards of the states. The purpose of this study is to evaluate Smoke-free Foster Care Education training among foster and adoptive parents in Georgia.
Methods
We partnered with Family and Children Services and the Administration for Children and Family to provide education about SHS to the families they serve in Georgia. We developed a brief 1.5 hour training to educate foster and adoptive parents in Georgia on the dangers of secondhand smoke, the benefits of a smoke-free home and steps to creating a smoke-free home. The overall goal of the training was to encourage foster caregivers to make their homes smoke-free. The training content was adapted from the intervention component of a randomized controlled trial to promote smoke-free homes among low-income populations (Kegler et al., 2015; Kegler et al., 2012). The content was structured to provide background information and then a more detailed description of a Smoke-free Foster Care Homes Kit. The kit consisted of these components: a smoke-free homes booklet, a flier about thirdhand smoke, a pledge, window cling and a sticker. The booklet discussed five steps of creating a smoke-free home, including 1) deciding to create a smoke-free home, 2) talking to household members about making a home smoke-free, 3) setting a date for going smoke-free, 4) making a home smoke-free, and 5) keeping the home smoke-free. The presentation began with the definition of secondhand smoke, statistics on secondhand smoke exposure, and dangers of secondhand smoke for babies, young children, teenagers and adult nonsmokers. We discussed the disease burden of SHS and its negative health impact such as asthma in children and lung cancer in adults, as well as the concept of thirdhand smoke. Thirdhand smoke was defined as the harmful elements of cigarette smoke that remain on surfaces after the visible smoke is gone, and contains nicotine and other toxic chemicals. The final phase of the training focused on the definition of a smoke-free home, the benefits of having a smoke-free home, and how to create a smoke-free home using the 5 steps of the smoke-free home intervention adapted from an earlier study (Kegler et al., 2015; Kegler et al., 2012). Parents of the in person training were given a Smoke-free Homes Foster care kit.
The training was delivered to foster and adoptive parents across the state of Georgia in November and December 2013. We utilized various avenues to reach foster and adoptive parents through promotion with the Georgia Center for Resources and Support webinar, a county level foster and adoptive parent meeting and two foster care summit events throughout the state. This training evaluation received a research exemption status from the Emory Institutional Review Board.
Training Evaluation Survey
At the end of each training, we administered an evaluation survey to all participants. Participants were asked to rate the presentation content and the presenters effectiveness on a 5-point scale of strongly disagree to strongly agree. For knowledge gained, participants were also asked to rate the extent to which the training helped them learn about secondhand smoke, thirdhand smoke, the benefits of a smoke-free home, the dangers of secondhand smoke, the 5-steps to create a smoke-free home, and how to address challenges in creating a smoke-free home. These items were also rated on a 5 point scale from 1=strongly disagree to 5=strongly agree. Additional questions asked participants about their thoughts as to how problematic SHS is in foster homes and establishment of a smoke-free policy in foster homes. Demographic information including age, gender race/ethnicity, type of parent (foster or adoptive), and number of children in the home, was assessed. Finally, we asked about smoking history, household smoking rules, and thoughts about continuing to be a foster parent if there was a policy to ban smoking in foster homes. Participants who completed the evaluation received 1.0 continuing education credits.
Data Analysis
Training participants either completed the evaluation online (for the training webinar) or on paper (for in-person training). Emory staff entered and analyzed the data in SPSS version 21.0. We ran descriptive statistics for the items, including frequencies, means, and percentages. We then ran a chi square test to assess the proportion of smoking bans among homes with smokers and non-smokers.
Results
There were 4 training events of 1 webinar and 3 in-person trainings. Overall, 195 foster and adoptive parents attended either the web-based training or in-person trainings. Of those in attendance 165 of them (84.6%) completed the evaluation survey. Most were foster parents (82.0%), 37.9% were adoptive/foster parents, 16.8% were in the pre-adoptive stage and 8.7% were adoptive parents only. Training attendees were majority female (57.4%) and mostly white (56.5%). The mean age of participants was 45.6 years (SD = 11.27) ranging from 21 – 78. On average, participants reported a household composition of 4.45 people (SD =2.25) and with 2.43 (SD=1.86) children under 18. About 33% of participants reported they had smoked at least 100 cigarettes in their entire life, and of those 10% currently smoke (n = 16). The average number of days smoked in the last 30 days was 22.13 days (SD = 9.97). Over 91% of homes reported full smoking bans, 5% reported a partial ban and 4% reported no ban (Table 1). About 7.6% of households with smokers reported total ban whereas 92.4% of households without smokers had one.
Table 1.
Characteristics of Foster/Adoptive parents
| Webinar (n=) | Site 1 (n=) | Site 2 (n=) | Site 3 (n=) | Total (N=) | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Mean | (SD) | Mean | (SD) | Mean | (SD) | Mean | (SD) | Mean | (SD) | |
| No. of household members | 3.07 | (1.39) | 4.39 | (2.27) | 3.30 | (2.26) | 5.11 | (2.20) | 4.45 | (2.25) |
| Children < 18 | 1.13 | (0.99) | 2.47 | (1.78) | 1.78 | (1.72) | 2.82 | (2.00) | 2.43 | (1.86) |
| N | (%) | N | (%) | N | (%) | N | (%) | N | (%) | |
| Type of parent* | ||||||||||
| Foster parent | 10 | (66.7) | 69 | (88.5) | 8 | (72.7) | 45 | (78.9) | 132 | (82.0) |
| Adoptive parent | 6 | (40.0) | 29 | (37.2) | 7 | (63.6) | 19 | (33.3) | 61 | (37.9) |
| Pre-adoptive | 3 | (20.0) | 15 | (19.2) | 1 | (9.1) | 8 | (14.0) | 27 | (16.8) |
| Hispanic origin | 1 | (6.7) | 2 | (2.5) | 0 | (0) | 1 | (1.8) | 4 | (2.5) |
| Race (n= 161) | ||||||||||
| White | 9 | (60.0) | 46 | (58.2) | 0 | (0) | 36 | (64.3) | 91 | (56.5) |
| Black | 3 | (19.9) | 28 | (35.5) | 11 | (100.0) | 18 | (32.1) | 60 | (37.3) |
| Asian/Pacific Islander | 1 | (6.7) | 1 | (1.3) | 0 | (0) | 0 | (0) | 2 | (1.2) |
| Multi-racial | 1 | (6.7) | 2 | (2.5) | 0 | (0) | 1 | (1.8) | 4 | (2.5) |
| Other | 1 | (6.7) | 2 | (2.5) | 0 | (0) | 1 | (1.8) | 4 | (2.5) |
| Gender (n = 162) | ||||||||||
| Male | 8 | (57.1) | 31 | (39.2) | 2 | (16.7) | 28 | (49.1) | 69 | (42.6) |
| Female | 6 | (42.9) | 48 | (60.8) | 10 | (83.3) | 29 | (50.9) | 93 | (57.4) |
| Age, Mean (SD) | 40.9 (6.83) | 44.1 (11.02) | 60.9 (11.05) | 45.9 (10.22) | 45.6 (11.27) | |||||
| Range | 31 – 53 | 21 – 70 | 39 – 78 | 24 – 70 | 21 - 78 | |||||
Respondent could choose more than 1 option.
The training was overwhelmingly well received (Table 2). Participants rated the overall training a mean score of 4.29 (SD=0.73). Overall, participants rated with high agreement that the training objectives were clearly defined (M=4.62, SD = 0.51), the presentation was easy to understand (M=4.66, SD = 0.49) and participation and interaction were encouraged (M=4.49, SD = 0.62). For the presenters, participants rated the presenters as effective in presenting the content (M=4.61, SD = 0.56) and were knowledgeable of the subject area (M=4.65, SD=0.52). For content learned, participants reported that they strongly agreed with most topics (Table 3). The topics that reported the highest values were: 5 steps to creating a smoke-free home (M=4.51, SD=0.63), benefits of a smoke-free home (M=4.50, SD=0.67), dangers of secondhand smoke (M=4.49, SD=0.66), and thirdhand smoke (M=4.47, SD=0.65).
Table 2.
Ratings of Training and Presenters
| N | Webinar | Site 1 | Site 2 | Site 3 | Total | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Mean | (SD) | Mean | (SD) | Mean | (SD) | Mean | (SD) | Mean | (SD) | ||
| The objectives of the training were clearly defined | 164 | 4.67 | (0.49) | 4.59 | (0.52) | 4.77 | (0.44) | 4.61 | (0.53) | 4.62 | (0.51) |
| The content was organized and easy to follow | 163 | 4.73 | (0.46) | 4.54 | (0.57) | 4.77 | (0.44) | 4.63 | (0.49) | 4.61 | (0.53) |
| The presentation was easy to understand | 163 | 4.87 | (0.35) | 4.65 | (0.51) | 4.77 | (0.44) | 4.61 | (0.49) | 4.66 | (0.49) |
| The PowerPoint served as a great visual aid | 162 | 4.73 | (0.46) | 4.46 | (0.64) | 4.58 | (0.52) | 4.46 | (0.68) | 4.49 | (0.63) |
| The presenters were effective in presenting the content | 118 | 4.67 | (0.49) | 4.48 | (0.67) | 4.77 | (0.44) | 4.63 | (0.52) | 4.61 | (0.56) |
| The presenters were knowledgeable of the subject area | 164 | 4.87 | (0.35) | 4.56 | (0.55) | 4.77 | (0.44) | 4.70 | (0.50) | 4.65 | (0.52) |
| Participation and interaction were encouraged | 164 | 4.80 | (0.41) | 4.48 | (0.62) | 4.54 | (0.52) | 4.40 | (0.68) | 4.49 | (0.62) |
Note: Response options were 1=Strongly disagree to 5=Strongly agree.
Table 3.
Learning about Training Content
| N | Webinar | Site 1 | Site 2 | Site 3 | Total | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Mean | (SD) | Mean | (SD) | Mean | (SD) | Mean | (SD) | Mean | (SD) | ||
| Secondhand smoke | 163 | 4.27 | (0.46) | 4.26 | (0.78) | 4.54 | (0.52) | 4.33 | (0.69) | 4.31 | (0.71) |
| Thirdhand smoke | 163 | 4.60 | (0.51) | 4.40 | (0.73) | 4.69 | (0.48) | 4.49 | (0.60) | 4.47 | (0.65) |
| The benefits of a smoke-free home | 163 | 4.67 | (0.49) | 4.40 | (0.77) | 4.69 | (0.48) | 4.54 | (0.60) | 4.50 | (0.67) |
| The dangers of secondhand smoke | 162 | 4.60 | (0.51) | 4.40 | (0.77) | 4.69 | (0.48) | 4.54 | (0.57) | 4.49 | (0.66) |
| The 5 steps to create a smoke-free home | 162 | 4.60 | (0.51) | 4.43 | (0.70) | 4.77 | (0.44) | 4.53 | (0.60) | 4.51 | (0.63) |
| How to address challenges to creating a smoke-free home | 163 | 4.67 | (0.49) | 4.36 | (0.77) | 4.69 | (0.48) | 4.46 | (0.63) | 4.45 | (0.69) |
Note: Response options were 1=Strongly disagree to 5=Strongly agree.
We also assessed whether foster/adoptive parent thought secondhand smoke in foster homes is a problem. A majority (79%) of the caregivers believed secondhand smoke exposure was very much a problem in foster homes. However, they also noted this was only a problem if smoking was actually allowed in the home. We also asked the participants if they would continue to be a licensed foster parent if DFCS decided to change the rules to ban smoking in foster care homes. The majority (90.5%) of parents reported that they would continue to be a foster parent and only 1.3% of parents reported that they would quit being foster parents. A few reported that they were not sure (2.5%) or that this question was or not applicable to them because they were not foster parents (5.7%).
Discussion
Results of the training showed that foster and adoptive caregivers valued the training and learned about many topics related to the dangers of secondhand smoke and the importance of a smoke-free home. They reported gaining the most knowledge about thirdhand smoke, benefits of a smoke-free home and steps to creating a smoke-free home. This is probably because thirdhand smoke is a newer concept for the communities (Escoffery et al., 2013) and that many public health efforts and education center on smoke-free policy development and smoking cessation. For foster agencies, it may be helpful to provide education on these topics for families who voluntarily desire to make their home smoke-free or families with medically fragile children exposed to secondhand smoke. In addition, they can offer continuing education credits as an incentive to participate in this educational topic. Additional supports can also be offered to promote the awareness of this issue. We developed a website, http://smokefreehomes.emory.edu/foster-care/index.html to supplement the foster and adoptive parent training and provide additional information. The website also includes a similar training for case workers and social services staff in Georgia, to help them identify families that allow smoking in the home, as well as guide them through the use of the smoke-free foster homes kit. These training and resources aim to increase smoke-free environments for foster kids because although the foster home is intended to be a temporary situation until a permanent living arrangement is arranged, many foster children remain in foster care for years. Data show that about 30% of foster children remain in foster care for 2 to 5 years (U.S. Department of Health and Human Services, 2010). The provision of education and training to foster and adoptive caregiver about the effects of tobacco exposure (second and third hand smoke) and the benefits of a smoke free policy is a recommended policy consideration for foster care agencies not yet ready to require smoke-free homes for foster children (Public Health Law Center, 2013).
In addition, we found that many parents would continue to foster if there was a mandate for their foster home to restrict smoking inside. This demonstrates foster parents’ support for smoking restrictions around children for states that are interested in instituting such a policy about banning smoking in foster and adoptive foster homes. Results from this study show that even families with smokers would support this mandate. This finding is similar, but slightly less than (91% versus 96%) than findings from a survey conducted by the Michigan Department of Human Services of their foster caregivers (Public Health Law Center, 2013). This has practical implications for the state of Georgia and other states that do not currently have smoke-free foster home policies. They can implement these restrictions at a statewide or local level for households desiring to foster children without fear of families not fostering due to the smoking ban policy.
There are several limitations to this evaluation. Participants may not be representative of all foster and adoptive caregivers since it was based on sites interested in receiving this training. Smoking and ban status were not verified but self-reported. We cannot be certain that foster parents who smoke inside their homes provided honest responses for fear that it might revoke their fostering status. Additional research can be done to validate self-reported responses and evaluate the outcomes of these trainings on actual creation of smoke-homes over time among foster caregivers to protect vulnerable children.
Given the fact that only half of the state foster care agencies prohibit smoking in foster homes or any vehicles when the foster child is present, there is still the need to promote smoke-free homes for families that foster or adopt children to protect their health and well-being. This training offers an opportunity to educate families about the harms of SHS and the benefits of a smoke-free home to reduce immediate and long-term health outcomes of secondhand smoke exposure.
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