Abstract
INTRODUCTION: The Smoke-Free Homes (SFH) Program is an evidence-based intervention offered within 2-1-1 information and referral call centers to promote smoke-free homes in low-income populations. We used the Consolidated Framework for Implementation Research to conduct a mixed-methods analysis of facilitators and barriers to scaling up SFH to five 2-1-1 sites in the United States. METHODS: Data were collected from staff in 2015-2016 via online surveys administered before (N = 120) and after SFH training (N = 101) and after SFH implementation (N = 79). Semi-structured telephone interviews were conducted in 2016 with 25 staff to examine attitudes towards SFH, ways local context affected implementation, and unintended benefits and consequences of implementing SFH. RESULTS: Post-implementation, 79% of respondents reported that SFH was consistent with their 2-1-1's mission, 70% thought it led to more smoke-free homes in their population, 62% thought it was easy to adapt, and 56% thought participants were satisfied. Composite measures of perceived appropriateness of SFH for 2-1-1 callers and staff positivity toward SFH were significantly lower post-implementation than pre-implementation. In interviews, staff said SFH fit with their 2-1-1's mission but expressed concerns about intervention sustainability, time and resources needed for delivery, and how SFH fit into their workflow. CONCLUSIONS: Sites' SFH implementation experiences were affected both by demands of intervention delivery and by SFH's perceived effectiveness and fit with organizational mission. Future implementation of SFH and other tobacco control programs should address identified barriers by securing ongoing funding, providing dedicated staff time, and ensuring programs fit with staff workflow. IMPLICATIONS: Smoke-free home policies reduce exposure to secondhand smoke. Partnering with social service agencies offers a promising way to scale up evidence-based smoke-free home interventions among low-income populations. We found that the SFH intervention was acceptable and feasible among multiple 2-1-1 delivery sites. There were also significant challenges to implementation, including site workflow, desire to adapt the intervention, time needed for intervention delivery, and financial sustainability. Addressing such challenges will aid future efforts to scale up evidence-based tobacco control interventions to social service agencies such as 2-1-1.