Indigenous women and smoking during pregnancy: knowledge, cultural contexts and barriers to cessation

First Nations Peoples' perceptions, knowledge and beliefs regarding stillbirth prevention and bereavement practices: A mixed methods systematic review

BACKGROUND

First Nations Peoples endure disproportionate rates of stillbirth compared with non-First Nations Peoples. Previous interventions have aimed at reducing stillbirth in First Nations Peoples and providing better bereavement care without necessarily understanding the perceptions, knowledge and beliefs that could influence the design of the intervention and implementation.

AIM

The aim of this review was to understand the perceptions, knowledge and beliefs about stillbirth prevention and bereavement of First Nations Peoples from the US, Canada, Aotearoa/New Zealand, and Australia.

METHODS

This review was conducted in accordance with the JBI methodology for a convergent integrated mixed method systematic review. This review was overseen by an advisory board of Aboriginal Elders, researchers, and clinicians. A search of eight databases (PubMed, MEDLINE, PsycInfo, CINAHL, Embase, Emcare, Dissertations and Theses and Indigenous Health InfoNet) and grey literature was conducted. All studies were screened, extracted, and appraised for quality by two reviewers and results were categorised, and narratively summarised.

RESULTS

Ten studies were included within this review. Their findings were summarised into four categories: safeguarding baby, traditional practices of birthing and grieving, bereavement photography and post-mortem examination. The results indicate a diversity of perceptions, knowledge and beliefs primarily around smoking cessation and bereavement practices after stillbirth. However, there was a paucity of research available.

CONCLUSIONS

Further research is needed to understand the perceptions, knowledge and beliefs about stillbirth among First Nations Peoples. Without research within this area, interventions to prevent stillbirth and support bereaved parents and their communities after stillbirth may face barriers to implementation.

My quitting stories: A qualitative study exploring Aboriginal women's experiences of smoking cessation and preventing relapse in the context of pregnancy

BACKGROUND

Most women who give up smoking during pregnancy relapse to smoking postnatally. Evidence on strategies that are helpful in maintaining smoking cessation during and beyond pregnancy is limited.

AIM

This paper aims to explore Aboriginal women's experiences of quitting smoking, relapsing, and preventing relapse, focusing on the strategies they applied for attaining and maintaining abstinence and the support they received.

METHODS

Qualitative interviews were conducted between October 2020 and June 2021, in urban New South Wales, Australia, with 12 Aboriginal women who either smoked tobacco or quit smoking and had been pregnant in the last five years. Aboriginal Research Assistants recruited participants, participated in data collection and data analysis. Data were thematically analysed.

RESULTS

Major themes that emerged from the data include: a) aspiration to be abstinent; b) strong mindset; c) strategies to stay smoke-free; d) supports received; and e) service and policy recommendations. Protecting children from second-hand smoke had salience for the maintenance of abstinence. Having a strong mindset was perceived as a prerequisite to staying smoke-free. Use of multiple coping strategies in combination was frequently expressed. Knowledge about tobacco-related harms, the way nicotine dependence works, and the available support options was empowering and enabled informed decision making and actions around smoking cessation.

CONCLUSION

This qualitative study conducted with 12 Aboriginal women revealed that Aboriginal women employ multiple strategies (cognitive, behavioural and social) to quit smoking and stay smoke-free. The strategies warrant further exploration with different Aboriginal communities across Australia and consideration of inclusion in smoking cessation care.

Engaging with a rural Aboriginal community to identify strategies to improve oral health within their community: a qualitative study

BACKGROUND

Aboriginal and Torres Strait Islanders bear a higher burden of oral disease compared to non-Indigenous persons. Rural Aboriginal and Torres Strait Islander communities are further disadvantaged due to service access difficulties. This study, initiated by community concern for oral health identified through its Health Action Group, aimed to explore a rural Aboriginal community's strategies to resolve oral health problems.

CONCLUSION

Community members are aware of local barriers and potential facilitators for improving oral health within their community. Their identification of priority strategies can be used to inform the delivery of oral healthcareservices and to develop oral healthcare promotion programs for the community. Co-designing solutions with the community should be an integral part of solving complex problems such as oral health.

METHODS

A qualitative research study using a phenomenological research design with focus group discussions and in-depth interviews was completed in partnership with a rural community in Queensland, Australia, with a predominantly Aboriginal population. The research team included Aboriginal and non-Aboriginal personnel; community and external personnel; and dental and non-dental personnel. The collaborative approach included the development, implementation, analysis and interpretation of the research involving the community through its Health Action Group. Community engagement led to the recruitment of 27 participants from local health and community groups.

RESULTS

Themes emerging from the data included: reducing financial barriers to accessing oral health care; integrating oral health care with other health services; increasing oral healthcare promotion activities; and ensuring local input and cultural safety within local oral healthcare services.

The Western Australian preterm birth prevention initiative: a whole of state singleton pregnancy cohort study showing the need to embrace alternative models of care for Aboriginal women

BACKGROUND

Preterm birth (PTB) is the greatest cause of mortality and morbidity in children up to five years of age globally. The Western Australian (WA) PTB Prevention Initiative, the world's first whole-of-population whole-of-state program aimed at PTB prevention, was implemented across WA in 2014.

METHODS

We conducted a prospective population-based cohort study using pregnancy data for singleton births in WA from 2009 to 2019. Logistic regression using the last full year before the Initiative (2013) as the reference, and run charts were used to examine changes in PTB rates compared to pre-Initiative levels, by gestational age group, hospital type, low and high risk of PTB in mid-pregnancy, and onset of labour (spontaneous/medically initiated). Analyses were stratified by Aboriginal and non-Aboriginal maternal ethnicity.

RESULTS

Amongst non-Aboriginal women, there was initially a reduction in the PTB rate across the state, and in recent years it returned to pre-Initiative levels. Amongst Aboriginal women there was a small, non- significant reduction in the state-wide PTB rate in the first three years of the Initiative, followed by a rise in recent years. For non-Aboriginal women, the reduction in the rate of PTB at the tertiary centre was sustained and improved further for women of all risk levels and onsets of labour. This reduction was not observed for Aboriginal women giving birth at the tertiary centre, amongst whom there was an increase in the PTB rate overall and in all subgroups, with the exception of medically initiated PTB. Amongst Aboriginal women the PTB rate has also increased across the state. At non-tertiary hospitals there was a large increase in PTB amongst both Aboriginal and non-Aboriginal women, largely driven by medically initiated late PTB. Maternal risk factors cannot account for this increase.

CONCLUSIONS

The reduction in PTB rates amongst non-Aboriginal women at the state's tertiary hospital demonstrates that with the right strategies, PTB can be reduced. A sustained collaborative model is required to realise this success in non-tertiary hospitals. The series of interventions was of limited use in Aboriginal women, and future efforts will need to be directed at strategies more likely to be successful, such as midwifery continuity of care models, with Aboriginal representation in the healthcare workforce.

"It Needs a Full-Time Dedicated Person to Do This Job in Our Local Communities with Our Aboriginal Health Services"-Aboriginal and Torres Strait Islander Health Workers and Practitioners Perspectives on Supporting Smoking Cessation during Pregnancy

BACKGROUND

Aboriginal and Torres Strait Islander women deserve improved smoking cessation support. Aboriginal health workers (AHW) and practitioners (AHP) can be central to the provision of culturally safe smoking cessation care (SCC). The objective of this study is to explore attitudes and the perceived role of AHWs/AHPs toward providing SCC to Aboriginal and Torres Strait Islander pregnant women.

METHOD

A mixed-method study using quantitative and qualitative data was conducted among AHW/AHPs in 2021 across Australia. Descriptive and analytical statistics were used to characterise AHWs'/AHPs' attitudes towards SCC and to evaluate the factors associated with perceptions of who is best placed to provide SCC.

RESULTS

From the total AHW/AHP workforce, 21.2% (223) completed the survey. Less than half (48.4%) believed that AHW/AHP were best placed to provide SCC for pregnant women. The majority believed that group-based supports (82.5%) and cultural support programs (63.7%) were the best strategies to support Aboriginal and Torres Strait Islander pregnant women to quit smoking.

CONCLUSION

This study highlights the need to enhance SCC offered to Aboriginal and Torres Strait Islander pregnant women. A targeted workforce dedicated to smoking cessation should be resourced, including funding, standardised training, and ongoing SCC support tailored to Aboriginal and Torres Strait Islander pregnant women.

Psychological Distress, Stressful Life Events and Social Disadvantage in Pregnant Indigenous Australian Women Residing in Rural and Remote NSW: a Longitudinal Cohort Study

BACKGROUND

Pregnancy can be a stressful time for many women. Australian Indigenous women of childbearing age (18-44 years) have been found to experience high or very high rates of psychological distress. However, few studies have examined the burden of or any associations between stressful life events, social disadvantage and psychological distress for pregnant Indigenous women in Australia.

METHODS

Two hundred sixty-one rural and remote women, pregnant with an Indigenous infant, from New South Wales in Australia were invited to provide data regarding social disadvantage then complete the Kessler-10 and Stressful Life Events surveys via self-report during each trimester of their pregnancy. Descriptive statistics, Pearson's correlations, Mann-Whitney U and Kruskal-Wallis tests were performed to determine the burden of and any associations between the variables of interest.

RESULTS

High rates of psychological distress were reported by participants with 16.9% scoring severe distress levels during their pregnancy. Participants also reported high rates of stressful life events with almost 25% experiencing the death of a family member or friend, almost 14% living in overcrowded accommodation, 11% having someone close to them jailed and 8% experience separation from their partner, during their pregnancies. Distress was associated with numerous stressful life events (e.g. witnessing violence, a family member in jail and overcrowding) and one aspect of social disadvantage (smoking status).

CONCLUSIONS

Immediate attention needs to focus on the development of interventions to address the high levels of psychological distress and provide appropriate support services during periods of major life events for pregnant Australian Indigenous women.

Smoking and quitting characteristics of Aboriginal and Torres Strait Islander women of reproductive age: findings from the Which Way? study

OBJECTIVE

To describe smoking characteristics, quitting behaviour and other factors associated with longest quit attempt and the use of nicotine replacement therapy (NRT) and stop-smoking medication (SSM) in a population of Indigenous Australian women of reproductive age.

DESIGN, SETTING AND PARTICIPANTS

A national cross-sectional survey of Aboriginal and Torres Strait Islander women aged 16-49 years who were smokers or ex-smokers was conducted online during the period July to October 2020.

MAIN OUTCOME MEASURES

Quitting experience: attempt to cut down, time since last quit attempt, longest period without smoking, attempt to cut down during last quit attempt, any use of NRT and/or SSM.

RESULTS

Most of the 428 participating women (302 [70.6%]) reported using an Aboriginal health service. Younger women (16-20-year-olds) smoked fewer cigarettes daily (24/42 [57.1%], 0-5 cigarettes per day), waited longer to smoke after waking (20/42 [47.6%], > 60 minutes after waking), and were categorised as low smoking dependency compared with those aged 35 years and over. One-third of women (153 [35.7%]) had ever used NRT and/or SSM. A greater proportion of older women (35-49-year-olds) had sustained a quit attempt for years (62/149 [45.6%]) and reported trying NRT and/or SSM (78/149 [52.4%]) than women in younger age groups. Quitting suddenly rather than gradually was significantly associated with sustained abstinence (prevalence ratio, 1.27 [95% CI, 1.10-1.48]). Among women who had never used NRT or SSM, most (219/275 [79.6%]) reported reasons for this in the category of attitudes and beliefs. NRT and SSM use was also more likely among women who were confident talking to their doctor about quitting (odds ratio, 2.50 [95% CI, 1.23-5.10]) and those who received most of their information from a health professional (odds ratio, 1.71 [95% CI, 1.11-2.63]).

CONCLUSION

Aboriginal and Torres Strait Islander women want to quit smoking and are making attempts to quit. Quitting suddenly, rather than reducing cigarette consumption, is associated with increased sustained abstinence. Health providers can enable access and uptake of NRT and/or SSM and should recognise that NRT and/or SSM use may change over time. Consistent messaging, frequent offers of smoking cessation support, and access to a range of smoking cessation supports should be provided to Aboriginal and Torres Strait Islander women to enable them to be smoke-free.

Understanding Determinants of Pregnant Women's Knowledge of Lifestyle-Related Risk Factors: A Cross-Sectional Study

Research indicates that a woman’s lifestyle during pregnancy influences her child’s health and development. Therefore, women need to possess sufficient knowledge regarding the elements of a healthy lifestyle during pregnancy. To date, there has been little research on the assessment of lifestyle knowledge of pregnant women in the perinatal healthcare setting. This study describes the development and application of a knowledge-based questionnaire for pregnancy to be used in a lifestyle intervention trial conducted in Germany. Within the trial, pregnant women receive counselling on lifestyle topics. These topics are based on the German initiative ‘Healthy Start—Young Family Network’ (GiL), which provides evidence-based recommendations regarding diet and lifestyle before and during pregnancy. These serve as a basis for health professionals who provide counselling on healthy lifestyle choices during the antenatal period. The questionnaire consists of eight items, each of which can be answered using ‘Yes’, ‘No’ or ‘Don’t know’. The pregnant women who completed the questionnaire at baseline around the twelfth week of gestation were recruited within the host trial from gynaecological practices in Germany. Demographic variables and the respondents’ answers to the questionnaire were analysed using descriptive statistics and regression analyses. Descriptive statistics show that more than 85% of participants answered the majority of questions (n = 5) correctly. Questions on whether tap water is safe and the normal range for gestational weight gain (GWG) were answered correctly by about 62% and 74% of the women, respectively, and the question on whether it is beneficial to obtain information on breastfeeding at an early stage was answered correctly by about 29%. The results of the regression analyses indicate that age, gestational week, education and income are positive predictors for answering the questionnaire correctly. Nullipara and migration background are predictors for answering the questions incorrectly. This study indicates that there are gaps in women’s knowledge regarding lifestyle during pregnancy. Particular focus on certain topics, such as breastfeeding and normal GWG ranges, is still required during counselling. Our analysis shows that migration background is a predictor of insufficient knowledge and incorrect answers to the questions. Women with such backgrounds require special attention during antenatal counselling in order to cater to their needs and the gaps in their knowledge.

"Does this dental mob do eyes too?": perceptions and attitudes toward dental services among Aboriginal Australian adults living in remote Kimberley communities

BACKGROUND

Australian Aboriginal and Torres Strait Islander people continue to experience significant disparities in oral health and there remains an urgent need to improve services to rural and remote communities. Quantitative research has typically been used to highlight the disease burden and severity experienced by those living in remote communities, but this data does little to explore the lived reality and psychosocial nuances that impact on care. The Kimberley region of Western Australia is home to over 150 Aboriginal communities spread out across 400,000 square kilometres. The success and sustainability of oral health services to these remote communities relies on respect and reciprocity achieved through shared knowledge, decision making and involvement of Aboriginal people in discussions around oral health services and their delivery. This, study aimed to investigate the perceptions and attitudes toward dental services among Aboriginal Australian families living in remote Kimberley communities.

METHODS

Semi-structured interviews and yarning circles were carried out following purposive sampling of Aboriginal adults living in the East Kimberley region of Western Australia. Interviews were recorded, transcribed, and analysed guided by a constructivist grounded theory approach.

RESULTS

In total, 80 community members participated in the yarning process. Enablers to care included: promotion of existing services, integration with primary health services, using mobile dental services and volunteers to extend care. Barriers to care included transportation, cost of treatment, the complexity of appointment systems and shame associated with health-seeking behaviours.

CONCLUSIONS

Reassessing the prevailing operative model of dental care to remote Aboriginal communities is warranted to better address the overwhelming structural barriers that impact on oral health. Integration with existing primary health services and schools, the use of mobile units to extend care and increasing community engagement through clinical yarning are recommended in improving the current state of dental services to communities in the Kimberley.

Factors Associated with Smoke-Free Pregnancy among Aboriginal and Torres Strait Women and Their Experience of Quitting Smoking in Pregnancy: A Mixed Method Cross-Sectional Study

Smoke-free pregnancies have long-term health benefits for mothers and babies. This paper quantitatively examines factors associated with smoke-free pregnancies among Aboriginal and Torres Strait Islander women (hereafter Aboriginal women) and qualitatively explores their smoking cessation (SC) experiences during pregnancy. An Aboriginal-led online cross-sectional study on SC was conducted with Aboriginal women and in partnership with Aboriginal communities, between July and October 2020. The present analysis includes participants who made a pregnancy-related quit attempt (N = 103). Chi-squared tests, logistic regression models, and thematic analysis of free-form text responses were performed. The adjusted odds of having smoke-free pregnancies were 4.54 times higher among participants who used Aboriginal Health Services (AHS) (AOR = 4.54, p-value 0.018). Participants living in urban settings had 67% lower odds of having smoke-free pregnancies compared to their regional/remote counterparts (AOR = 0.33, p-value 0.020). Qualitative data revealed strong motivations to reduce tobacco-related harms to the fetus and variability in quitting experiences at different stages of and across pregnancies. Smoking cessation care (SCC) can support Aboriginal women meaningfully if their quitting experiences are considered in SCC development and implementation. Consistent funding for AHS-led SCC is needed to garner health benefits for Aboriginal peoples. More research into urban versus regional/remote differences in maternal SC is recommended.

Smoking Cessation Messages for Pregnant Aboriginal and Torres Strait Islander Women: A Rapid Review of Peer-Reviewed Literature and Assessment of Research Translation of Media Content

This review summarized literature about knowledge, attitudes, and beliefs of Aboriginal and Torres Strait Islander women from Australia who smoke during pregnancy, then examined the extent that existing health promotion materials and media messages aligned with evidence on smoking cessation for pregnant Aboriginal and Torres Strait Islander women. Knowledge, attitudes, and beliefs of pregnant Aboriginal women who smoke tobacco were identified in the literature. Health promotion campaigns were retrieved from a grey literature search with keywords and social and professional networks. Key themes from peer-reviewed papers were compared against the content of health promotion campaigns using the Aboriginal Social and Emotional Wellbeing Model, the Behavior Change Wheel and thematic analysis. Eleven empirical studies and 17 campaigns were included. Empirical studies highlighted women sought holistic care that incorporated nicotine replacement therapy, engaged with their family and community and the potential for education about smoking cessation to empower a woman. Health promotion campaigns had a strong focus on ‘engagement with family and community’, ‘knowledge of risks of smoking,’ ‘giving up vs cutting down’ and ‘culture in language and arts’. There were similarities and variances in the key themes in the research evidence and promotion materials. Topics highly aligned included risks from smoking and quitting related issues.

A better start to life: Risk factors for, and prevention of, preterm birth in Australian First Nations women - A narrative review

The unacceptable discrepancies in health outcomes between First Nations and non-Indigenous Australians begin at birth. Preterm birth (birth before 37 completed weeks of gestation) is a major contributor to adverse short- and long-term health outcomes and mortality. Australian First Nations infants are more commonly born too early. No tangible reductions in preterm births have been made in First Nations communities. Factors contributing to high preterm birth rates in Australian First Nations infants are reviewed and interventions to reduce preterm birth in Australian First Nations women are discussed. More must be done to ensure Australian First Nations infants get a better start to life. This can only be achieved with ongoing and improved research in partnership with Australian First Nations peoples.

Health providers' and pregnant women's perspectives about smoking cessation support: a COM-B analysis of a global systematic review of qualitative studies

Background

Smoking cessation in pregnancy has unique challenges. Health providers (HP) may need support to successfully implement smoking cessation care (SCC) for pregnant women (PW). We aimed to synthesize qualitative data about views of HPs and PW on SCC during pregnancy using COM-B (Capability, Opportunity, Motivation, Behaviour) framework.

Methods

A systematic search of online databases (MEDLINE, EMBASE, PsycINFO and CINAHL) using PRISMA guidelines. PW’s and HPs’ quotes, as well as the authors’ analysis, were extracted and double-coded (30%) using the COM-B framework.

Results

Thirty-two studies included research from 5 continents: twelve on HPs’ perspectives, 16 on PW’s perspectives, four papers included both. HPs’ capability and motivation were affected by role confusion and a lack of training, time, and resources to provide interventions. HPs acknowledged that advice should be delivered while taking women’s psychological state (capability) and stressors into consideration. Pregnant women’s physical capabilities to quit (e.g., increased metabolism of nicotine and dependence) was seldom addressed due to uncertainty about nicotine replacement therapy (NRT) use in pregnancy. Improving women’s motivation to quit depended on explaining the risks of smoking versus the safety of quit methods. Women considered advice from HPs during antenatal visits as effective, if accompanied by resources, peer support, feedback, and encouragement.

Conclusions

HPs found it challenging to provide effective SCC due to lack of training, time, and role confusion. The inability to address psychological stress in women and inadequate use of pharmacotherapy were additional barriers. These findings could aid in designing training programs that address HPs’ and PW’s attitudes and supportive campaigns for pregnant smokers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03773-x.

Smoking Cessation during the Second Half of Pregnancy Prevents Low Birth Weight among Australian Born Babies in Regional New South Wales

Smoking during pregnancy is a modifiable risk behavior of adverse health outcomes including low birth weight (LBW), and LBW is a key marker of newborns immediate and future health. This study aimed to examine the association between smoking cessation during the second half of pregnancy and LBW among babies born in Southern New South Wales Local Health District (SNSWLHD). Routinely collected perinatal data on singleton live births for the period 2011–2019 in five public hospitals of SNSWLHD were utilized. Multivariate logistic regression models were fitted to examine the association between smoking cessation during the second half of pregnancy and LBW. Analyses showed that mothers who ceased smoking during the second half of pregnancy were 44% less likely to have LBW babies (adjusted odds ratio (aOR) = 0.56; 95% confidence interval (CI): 0.34, 0.94) compared to those who continued smoking throughout pregnancy. Mothers who reported an average daily dose of 1–10 or >10 cigarettes during the second half of pregnancy were significantly more likely to have babies with LBW than those who ceased smoking during the second half of pregnancy. Early identification of smoking behavior and promotion of smoking-cessation intervention for risk populations including pregnant women within the older age bracket (35–49 years) is imperative to reduce LBW.

An ecological model of drug and alcohol use and related harms among Aboriginal and Torres Strait Islander Australians: A systematic review of the literature

Globally, Indigenous populations experience a disproportionately higher burden of disease related to substance use. Effective prevention of harm related to substance use is a key strategy for improving the health and wellbeing of Aboriginal and Torres Strait Islander peoples in Australia. To inform preventative approaches, this review synthesised the evidence of risk and protective factors of substance use and related harms among Aboriginal and Torres Strait Islander peoples. Eight peer-reviewed and two grey literature databases were systematically searched for quantitative or qualitative studies assessing factors associated with substance use and related harms among Aboriginal and Torres Strait Islander peoples, published between 1 January 1990 and 30 April 2018. Study quality was assessed using validated instruments. Risk or odds ratios were extracted or calculated and factors were summarised in an ecological model into individual, relationship, community, societal or culturally-distinct levels. Thirty-eight relevant studies were identified and reviewed. Individual-level risk factors for substance use were identified including low socio-economic status, high psychological distress, poly drug use and being male. Relationship-level factors were peer pressure and partner/family substance use; protective factors were supportive environments and positive role models. Community-level risk factors included availability of substances. Culturally-distinct factors included cultural connection as a protective factor, but cultural obligations around sharing was a risk factor. Societal risk factors included intergenerational trauma caused by government policies. These findings highlight the importance of tailored preventative approaches for Aboriginal and Torres Strait Islander communities that address identified risk factors and promote protective factors across all ecological levels.

Socioecological Mapping of Barriers and Enablers to Smoking Cessation in Indigenous Australian Women During Pregnancy and Postpartum: A Systematic Review

Background

With a high prevalence of smoking during pregnancy and limited Indigenous-specific evidence for treatment, we used socioecological mapping to identify multilevel barriers and enablers to smoking cessation related to Indigenous Australian pregnant and postpartum women.

Methods

Nine electronic databases were searched. Original studies except interventions and trials, published in English, up to February 29, 2020 were included. Studies were appraised using the QualSyst tool. Evidence was narratively synthesized. The review protocol was registered with PROSPERO (CRD42019135543).

Results

A total of 15 studies (10 quantitative, 5 qualitative) were included, covering 1306 women, 3 partners/family members, 234 health professionals (HP), and 2755 patient records. Complex and overlapping barriers were identified at individual, family, community, societal, and system levels. Socioeconomic disadvantages, inequality, and pervasive racism as legacies of colonization, combined with personal, family, and community circumstances intensified individual experiences of stress, which may be heightened during pregnancy. Inadequate smoking cessation care (SCC), inconsistent antitobacco messages, and ineffectual HP interventions underscore a need for service enhancement and further evidence to develop culturally relevant messages. High motivation of pregnant women to quit, resilience, and supports available in the family and community are strengths that warrant attention in future interventions.

Conclusions

SCC without ameliorating the social disadvantages and the disparities in health determinants between Indigenous and non-Indigenous Australian women may limit the effectiveness of SCC. A comprehensive approach is required that includes policy changes for addressing external stressors the women experience, engagement of family and community, and better training of HP and provision of free pharmacotherapy.

Implications

To systematically address barriers to smoking cessation at multiple levels, initiatives to ameliorate social disadvantages and discrepancies in social determinants of health between Indigenous and non-Indigenous Australians are required to be taken in tandem with SCC. Initiatives may include making relevant policy changes and allocating more resources for education, employment, housing, and community development. Enhancement of knowledge, skills, and confidence of HP regarding the provision of high-quality SCC for Indigenous women and their families is warranted. Future interventions may build on high motivation, resilience, and strengths of individual women, and incorporate support strategies engaging family and community.

Improving Aboriginal Maternal Health by Strengthening Connection to Culture, Family and Community

(1) Background: To explore the function of smoking in Aboriginal women’s lives from a trauma-informed, women-centred approach in order to inform the design of a culturally meaningful smoking cessation program for women living in the Pilbara, Western Australia; (2) Methods: Qualitative and Community Based Participatory Action Research (CBPAR) was used to discover what Aboriginal women know about smoking, the specific contextual issues that influence their smoking, and what community supports are available to help them quit smoking. Inductive analysis was used to determine key themes; (3) Results: 25 Aboriginal women (smokers, non-smokers, and ex-smokers) participated in focus groups or individual interviews. Women smoked to deal with stress, trauma and for maintaining social connections. Women who stopped smoking did so on their own when the reason was important enough or when they saw alternative ways of living. Creating safe places to bring women together to yarn about women’s business and link with health services was identified as critical to support women to stop smoking. Conclusions: Strategies to address smoking need to bring community, culture and health together in a meaningful way for women and their families; build on existing community strengths; and educate communities about the effects of smoking, and health professionals about how to support women to stop smoking.

Miscommunication and misperceptions between health staff and Indigenous carers about raising smoking cessation in a paediatric ward in Australia: a qualitative study

Background: Communication with indigenous patients is often a problem for health staff in Australia. Aim: This paper examines the barriers and enablers in communication between health staff and Indigenous carers of paediatric patients in a hospital, about advice to help reduce exposure of children to second-hand smoke (SHS). Methods: Non-indigenous health staff and Indigenous carers, were recruited from a paediatric ward of a regional hospital in the Northern Territory. A constructivist grounded theory with multiphase case study design and semi-structured interviews was used. Results: Health staff and carers had different perceptions about raising the issue of smoking. Health staff lacked confidence to talk about smoking and questioned the cultural appropriateness of doing so. In contrast, carers expected to talk about smoking while in the hospital., and perceived it as part of a caring and protective relationship by health staff. English being a second language for carers was considered a significant communication barrier by staff; carers, however, felt that health staff needed to modify their communication styles. The possible misperceptions about carers' lack of response to messages, led to health staff dropping the subject, when, in fact, carers were struggling with health workers communication styles. Conclusions: Health staff and carers perceive discussion around smoking differently. Cross-cultural communication education may empower staff to provide effective smoking cessation interventions in this setting. Impact statement: Improving communication between health staff will help ensure the optimal provision of smoking cessation support to carers.

Factors Affecting Smoking Behaviors and Smoking Prevalence in Pregnancy and Postpartum Period of Women

Aim

This study aimed to determine the factors affecting smoking behaviors and smoking prevalence among women during pregnancy and postpartum period.

Method

This cross-sectional study was conducted between May 2012 and October 2012 on a sample of 640 women who had children aged between one and three years and who enrolled in any one of the 23 family health centers located in the province of Sivas in Turkey. The data were collected through the questionnaires created by the researchers by interviewing the participants face to face in own homes. The data obtained were analyzed using the Statistical Package for the Social Sciences Statistics 15.0 (SPSS Inc.; Chicago, IL, USA) package program and evaluated using number, percentage distribution, chi square test, logistic regression analysis and Kaplan-Meier survival analysis.

Results

Smoking prevalence was found to be 8% during pregnancy and 15.6% in the postpartum period. It was determined that 17.2% of the women smoked before their last pregnancy (n=110), more than half of the smokers quit smoking during pregnancy (n=59), and 46.4% of them continued to smoke during pregnancy. It was determined that 79.7% of the participants who quit smoking during pregnancy relapsed within the first one to three years of the postpartum period, and only 20.3% continued not to smoke. The Kaplan-Meier survival analysis showed that women who breastfed quit smoking for a significantly longer time (27.6 months) compared with those who did not breastfeed (12 months). According to the logistic regression analysis, the risk of postpartum relapse among women aged 30 years or more was 10.99-fold higher than women between the ages of 19 and 29.

Conclusion

The rate of pre-pregnancy smokers decreased in the pregnancy and increased in the postpartum period.

Factors influencing the uptake and use of nicotine replacement therapy and e-cigarettes in pregnant women who smoke: a qualitative evidence synthesis

BACKGROUND

Nicotine replacement therapy (NRT) delivers nicotine without the toxic chemicals present in tobacco smoke. It is an effective smoking cessation aid in non-pregnant smokers, but there is less evidence of effectiveness in pregnancy. Systematic review evidence suggests that pregnant women do not adhere to NRT as prescribed, which might undermine effectiveness. Electronic cigarettes (e-cigarettes) have grown in popularity, but effectiveness and safety in pregnancy are not yet established. The determinants of uptake and use of NRT and e-cigarettes in pregnancy are unknown.

OBJECTIVES

To explore factors affecting uptake and use of NRT and e-cigarettes in pregnancy.

SEARCH METHODS

We searched MEDLINE(R), CINAHL and PsycINFO on 1 February 2019. We manually searched OpenGrey database and screened references of included studies and relevant reviews. We also conducted forward citation searches of included studies.

SELECTION CRITERIA

We selected studies that used qualitative methods of data collection and analysis, included women who had smoked in pregnancy, and elicited participants' views about using NRT/e-cigarettes for smoking cessation or harm reduction (i.e. to smoke fewer cigarettes) during pregnancy.

DATA COLLECTION AND ANALYSIS

We identified determinants of uptake and use of NRT/e-cigarettes in pregnancy using a thematic synthesis approach. Two review authors assessed the quality of included studies with the Wallace tool. Two review authors used the CERQual approach to assess confidence in review findings. The contexts of studies from this review and the relevant Cochrane effectiveness review were not similar enough to fully integrate findings; however, we created a matrix to juxtapose findings from this review with the descriptions of behavioural support from trials in the effectiveness review.

MAIN RESULTS

We included 21 studies: 15 focused on NRT, 3 on e-cigarettes, and 3 on both. Studies took place in five high-income countries. Most studies contributed few relevant data; substantially fewer data were available on determinants of e-cigarettes. Many studies focused predominantly on issues relating to smoking cessation, and determinants of NRT/e-cigarette use was often presented as one of the themes. We identified six descriptive themes and 18 findings within those themes; from these we developed three overarching analytical themes representing key determinants of uptake and adherence to NRT and/or e-cigarettes in pregnancy. The analytical themes show that women's desire to protect their unborn babies from harm is one of the main reasons they use these products. Furthermore, women consider advice from health professionals when deciding whether to use NRT or e-cigarettes; when health professionals tell women that NRT or e-cigarettes are safer than smoking and that it is okay for them to use these in pregnancy, women report feeling more confident about using them. Conversely, women who are told that NRT or e-cigarettes are as dangerous or more dangerous than smoking and that they should not use them during pregnancy feel less confident about using them. Women's past experiences with NRT can also affect their willingness to use NRT in pregnancy; women who feel that NRT had worked for them (or someone they know) in the past were more confident about using it again. However, women who had negative experiences were more reluctant to use NRT. No trials on e-cigarette use in pregnancy were included in the Cochrane effectiveness review, so we considered only NRT findings when integrating results from this review and the effectiveness review. No qualitative studies were conducted alongside trials, making full integration of the findings challenging. Women enrolled in trials would have agreed to being allocated to NRT or control group and would have received standardised information on NRT at the start of the trial. Overall, the findings of this synthesis are less relevant to women's decisions about starting NRT in trials and more likely to help explain trial participants' adherence to NRT after starting it. We considered most findings to be of moderate certainty; we assessed findings on NRT use as being of higher certainty than those on e-cigarette use. This was mainly due to the limited data from fewer studies (only in the UK and USA) that contributed to e-cigarette findings. Overall, we judged studies to be of acceptable quality with only minor methodological issues.

AUTHORS' CONCLUSIONS

Consistent messages from health professionals, based on high-quality evidence and clearly explaining the safety of NRT and e-cigarettes compared to smoking in pregnancy, could help women use NRT and e-cigarettes more consistently/as recommended. This may improve their attitudes towards NRT or e-cigarettes, increase their willingness to use these in their attempt to quit, and subsequently encourage them to stay smoke-free.

Pregnancy and birth outcomes of mothers with intellectual disability and their infants: Advocacy needed to improve well-being

BACKGROUND

Pregnancy in women with intellectual disability (ID) is increasingly recognised, along with their increased likelihood of experiencing risk factors for adverse pregnancy and infant outcomes.

OBJECTIVES

We aimed to compare risks of socio-demographic, pregnancy and infant outcomes of women with ID to other women.

METHODS

All mothers with children born in Western Australia from 1983 to 2012 were linked to the population-based Intellectual Disability Exploring Answers database. Mothers with ID were matched by age and Aboriginality to a population sample of mothers without ID. Pregnancy and birth outcomes were compared for both groups and logistic regression was used to compare outcome risks.

RESULTS

Compared to non-Aboriginal mothers without ID, non-Aboriginal mothers with ID were more likely to be of low socio-economic status, be without partner, smoke antenatally and have pre-existing asthma. They had a 1.5 times increased risk of pregnancy complications, specifically pre-eclampsia, urinary tract infection, threatened preterm labour and post-partum haemorrhage. After adjustment for maternal medical conditions and pregnancy complications, infants of Aboriginal mothers with ID had twice the risk of preterm birth and 1.6 times the risk of having percentage of optimal head circumference <95% compared to infants of Aboriginal mothers without ID. Infants of both Aboriginal and non-Aboriginal mothers with ID were more likely to have percentage of optimal birth weight <85% compared to those without ID.

CONCLUSIONS

For mothers with ID, modifiable risk factors for adverse outcomes need addressing. They may require additional assistance during pregnancy, including more frequent consultations and support to assist with pregnancy management.

Experiences and cessation needs of Indigenous women who smoke during pregnancy: a systematic review of qualitative evidence

OBJECTIVES

The aim of this review was to identify and synthesize the best available evidence to address two questions: i) what is the experience of smoking during pregnancy for Indigenous women? and ii) what are the smoking cessation needs of Indigenous women who smoke during pregnancy?

INTRODUCTION

Smoking during pregnancy not only affects pregnant women's general health but also causes such serious problems as pre-term delivery, low birth weight, and sudden infant death. Rates of smoking during pregnancy are particularly high among Indigenous women. Learning about Indigenous women's experiences of smoking during pregnancy and associated smoking cessation needs is important to providing informed health care to them.

INCLUSION CRITERIA

The participants of interest were Indigenous women who smoked during a current or past pregnancy. The phenomena of interest were the experiences of smoking during pregnancy for Indigenous women and the smoking cessation needs of Indigenous women during pregnancy. The context was any community worldwide where pregnant Indigenous women live. Studies considered for this review were those in which qualitative data were gathered and analysed on the phenomena of interest, including mixed methods research.

METHODS

A comprehensive search was conducted for published studies in academic databases (i.e. PubMed, CINAHL, PsycINFO, Embase, Sociological Abstracts, SocINDEX, and Web of Science), unpublished studies in sources of gray literature (i.e. ProQuest Dissertations and Theses, OAIster, LILACS, MedNar, Google, Google Scholar, OpenGrey and relevant websites), and any additional studies in reference lists. Language and date limiters were not applied. The searches included all studies globally and were carried out on October 31, 2016. Studies that met the inclusion criteria were assessed for methodological quality by two reviewers independently, using the criteria of the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research. Descriptive details of each study accepted for this review were extracted in accordance with the elements of the JBI Data Extraction Form for Qualitative Research. The research findings that were relevant to the phenomena of interest and had participant voice were extracted from each included study and synthesized using the JBI meta-aggregative approach. The synthesized findings were assigned confidence scores in accordance with the JBI ConQual approach.

RESULTS

Thirteen studies were included in this review following careful consideration of the methodological quality of each study. The studies yielded a total of 116 research findings, which were grouped into 19 categories and then aggregated to form five synthesized findings. Confidence in the findings was determined to be low to very low (see ConQual Summary of Findings).

CONCLUSION

There is a small body of research evidence on Indigenous women's experiences of smoking during pregnancy and their smoking cessation needs. Confidence in the synthesized findings is constrained due to methodological limitations in many of the primary studies included in this review, along with mixed credibility of the research findings from across primary studies.

Aboriginal Wingadhan Birrang (woman's journey) of smoking cessation during pregnancy as they participate in the ICAN QUIT in pregnancy pilot step-wedge trial

BACKGROUND

Addressing smoking cessation during pregnancy among Aboriginal women is a national priority under the Closing the Gap campaign. There is a need to measure and report interventions to support Aboriginal women during pregnancy.

AIM

To quantitatively assess women's smoking experiences over a 12 week ICAN QUIT in Pregnancy program.

METHODS

Aboriginal women and/or women expecting an Aboriginal baby reported their smoking experiences through repeated cross-sectional survey at baseline, four weeks, and 12 weeks. Self-reported nicotine dependence measures (heaviness of smoking index, strength of urges and frequency of urges to smoke), intentions to quit smoking, quit attempts, use of nicotine replacement therapy were gathered as well as a carbon-monoxide measure at each time point.

RESULTS

Expectant mothers (n=22) of Aboriginal babies participated from six Aboriginal Community Controlled Health Services between November 2016 and July 2017. At 12 weeks women reported (n=17) low heaviness of smoking index 1.21 with high strength of urges 2.64 and frequency of urges 3.00; 12/13 (92%) reported likely/very likely to quit smoking, made a mean 1.67 number of quit attempts, three women (13.6%) quit smoking (validated); 5/16 (31%) reported using nicotine replacement therapy.

DISCUSSION

Participating women made multiple quit attempts demonstrating motivation to quit smoking. Smoking cessation interventions should be tailored to address high strength and frequency of nicotine dependence despite low consumption.

CONCLUSION

Prolonged smoking cessation support is recommended to address physical, behavioural and psychological aspect of smoking. Cessation support should address previous quitting experiences to assess smoking dependence and tailoring of support.

TRIAL REGISTRATION

Australian and New Zealand Clinicial Trials Registry (Ref #ACTRN12616001603404).

Understanding the experiences, perspectives and values of indigenous women around smoking cessation in pregnancy: systematic review and thematic synthesis of qualitative studies

Background

The prevalence of smoking during pregnancy among indigenous women approaches 50% and is associated with sudden infant death, pregnancy loss, preterm delivery, low birth weight, and anatomical deformity. This study aims to synthesise qualitative studies by reporting experiences, perceptions, and values of smoking cessation among pregnant indigenous women to inform potential interventions.

Method

A highly-sensitive search of MEDLINE, Embase, PsychINFO, and CINAHL, in conjunction with analysis of Google Scholar and reference lists of related studies was conducted in March 2018. We utilised two methods (thematic synthesis and an indigenous Māori analytical framework) in parallel to analyse data. Completeness of reporting in studies was evaluated using the Consolidated Criteria for Reporting Qualitative Studies (COREQ) framework.

Results

We included seven studies from Australia and New Zealand involving 250 indigenous women. Three themes were identified. Realising well-being and creating agency included giving the best start to baby, pride in being a healthy mum, female role models, and family support. Understanding the drivers for smoking included the impact of stress and chaos that hindered prioritisation of self-care, the social acceptability of smoking, guilt and feeling judged, and inadequate information about the risks of smoking. Indigenous women strongly preferred culturally responsive approaches to smoking cessation, placing value on programs designed specifically for and by indigenous people, that were accessible, and provided an alternative to smoking.

Conclusion

Future interventions and smoking cessation programmes might be more effective and acceptable to indigenous women and families when they harness self-agency and the desire for a healthy baby, recognise the high value of indigenous peer involvement, and embed a social focus in place of smoking as a way to maintain community support and relationships. Development and evaluation of smoking cessation programs for pregnant indigenous women and families is warranted.

A large proportion of poor birth outcomes among Aboriginal Western Australians are attributable to smoking, alcohol and substance misuse, and assault

Background

Aboriginal infants have poorer birth outcomes than non-Aboriginal infants. Harmful use of tobacco, alcohol, and other substances is higher among Aboriginal women, as is violence, due to factors such as intergenerational trauma and poverty. We estimated the proportion of small for gestational age (SGA) births, preterm births, and perinatal deaths that could be attributed to these risks.

Methods

Birth, hospital, mental health, and death records for Aboriginal singleton infants born in Western Australia from 1998 to 2010 and their parents were linked. Using logistic regression with a generalized estimating equation approach, associations with birth outcomes and population attributable fractions were estimated after adjusting for demographic factors and maternal health during pregnancy.

Results

Of 28,119 births, 16% of infants were SGA, 13% were preterm, and 2% died perinatally. 51% of infants were exposed in utero to at least one of the risk factors and the fractions attributable to them were 37% (SGA), 16% (preterm) and 20% (perinatal death).

Conclusions

A large proportion of adverse outcomes were attributable to the modifiable risk factors of substance use and assault. Significant improvements in Aboriginal perinatal health are likely to follow reductions in these risk factors. These results highlight the importance of identifying and implementing risk reduction measures which are effective in, and supported by, Aboriginal women, families, and communities.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2252-4) contains supplementary material, which is available to authorized users.

A mixed methods exploratory study tackling smoking during pregnancy in an urban Aboriginal and Torres Strait Islander primary health care service

Background

Pregnancy can be a time of joy and a time of significant stress. For many Aboriginal and Torres Strait Islander (hereafter, respectfully, Indigenous) women, cigarette smoking, even during pregnancy, is a socially sanctioned behavioural response to stress. Indigenous women smoke during pregnancy at higher rates than their non-Indigenous counterparts.

Methods

A mixed methods, exploratory study, undertaken in an urban, Indigenous primary health care service, tested the impact and acceptability of a smoking cessation intervention for women pregnant with an Indigenous baby, their significant other (SO), and their primary health care service. The intervention included case management, incentivised smoking cessation support and culturally-based art activities.

Results

Thirty-one pregnant women and 16 SOs participated. Nearly half attempted to quit at least once during the study, 36% (4/11) of pregnant women had quit at the 3 month assessment and two remained smoke free 1 month postpartum. Most participants self-reported a reduction in tobacco smoking. Exhaled CO confirmed this for SOs (mean reduction − 2.2 ppm/assessment wave, 95% CI: -4.0, − 0.4 ppm/assessment wave, p = 0.015) but not for pregnant women. Many participants experienced social and economic vulnerabilities, including housing and financial insecurity and physical safety concerns.

Conclusions

Tobacco smoking is normalised and socially sanctioned in Indigenous communities and smoking is frequently a response to the multitude of stressors and challenges that Indigenous people experience on a daily basis. Smoking cessation interventions for pregnant Indigenous women must be cognisant of the realities of their private lives where the smoking occurs, in addition to the impact of the broader societal context. Narrow definitions of success focussing only on smoking cessation ignore the psychological benefit of empowering women and facilitating positive changes in smoking behaviours. Our smoking cessation intervention supported pregnant women and their SOs to manage these stressors and challenges, thereby enabling them to develop a solid foundation from which they could address their smoking. A broad definition of success in this space is required: one that celebrates positive smoking behaviour changes in addition to cessation.

Prenatal stress and models explaining risk for psychopathology revisited: Generic vulnerability and divergent pathways

The present review revisits three hypothesized models that potentially could explain how prenatal maternal stress influences fetal development, birth outcomes, and subsequent developmental psychopathology. These models were mostly based on animal models, and new evidence for these models from human studies is evaluated. Furthermore, divergent trajectories from prenatal exposure to adversities to offspring affected outcomes are reviewed, including the comparison of studies on prenatal maternal stress with research on maternal substance use and maternal malnutrition during pregnancy. Finally, new directions in research on the mechanism underlying prenatal stress effects on human offspring is summarized. While it is concluded that there is abundant evidence for the negative associations between prenatal maternal stress and offspring behavioral, brain, and psychopathological outcomes in humans, there is no consistent evidence for specific mechanisms or specific outcomes in relation to stress exposure in utero. Rather, principles of multifinality and equifinality best describe the consequences for the offspring, suggesting a generic vulnerability and different pathways from prenatal adversities to developmental psychopathology, which complicates the search for underlying mechanisms. New and promising directions for research are provided to get a better understanding of how prenatal stress gets under the skin to affect fetal development.

A social-contextual investigation of smoking among rural women: multi-level factors associated with smoking status and considerations for cessation

INTRODUCTION

The social-contextual model of tobacco control and the potential mechanisms of the maintenance or cessation of smoking behavior among disadvantaged women, including rural residents, have yet to be comprehensively studied. The purpose of this study was to determine the association between selected individual, interpersonal, workplace, and neighborhood characteristics and smoking status among women in Appalachia, a US region whose residents experience a disproportionate prevalence of tobacco-related health disparities. These findings may assist in efforts to design and test scientifically valid tobacco control interventions for this and other disadvantaged populations.

METHODS

Women, 18 years of age and older, residing in three rural Ohio Appalachian counties, were recruited using a two-phase address-based sampling methodology for a cross-sectional interview-administered survey between August 2012 and October 2013 (N=408). Multinomial logistic regression was employed to determine associations between select multilevel factors (independent variables) and smoking status (dependent variable). The sample included 82 (20.1%) current smokers, 92 (22.5%) former smokers, and 234 (57.4%) women reporting never smoking (mean age 51.7 years).

RESULTS

In the final multivariable multinomial logistic regression model, controlling for all other significant associations, constructs at multiple social-contextual levels were associated with current versus either former or never smoking. At the individual level, for every additional year in age, the odds of being a former or never smoker increased by 7% and 6% (odds ratio (OR) (95% confidence interval(CI)): 1.07 (1.0-1.11) and 1.06 (1.02-1.09)), respectively, as compared to the odds of being a current smoker. With regard to depression, for each one unit increase in the Center for Epidemiologic Studies Depression Scale score, the odds of being a former or never smoker were 5% and 7% lower (OR(95%CI): 0.95(0.91-0.999) and 0.93(0.88-0.98)), respectively. Five interpersonal factors were associated with smoking status. As the social influence injunctive norm score increased by one unit, indicating perception of smoking to be more acceptable, the odds of being a former or never smoker decreased by 23% and 30%, respectively. For every one unit increase in the social participation score, indicating past-year engagement in one additional activity type, the odds of being a former or never smoker increased by 17% and 36%, respectively. For every 10% increase in the percentage of social ties in the participant's advice network who smoked, the odds of being a former or never smoker were 24% and 28% less, respectively. For every 0.1 unit increase in the E/I index, indicating increasing homophily on smoking in one's social network, the odds of being a former or never smoker were 20% and 24% less, respectively, in the time network, and 18% and 20% less, respectively, in the advice network. At the neighborhood level, for every one unit increase in neighborhood cohesion score, indicating increasing cohesion, the odds of being a former smoker or never smoker were 12% and 14% less, respectively.

CONCLUSIONS

These findings indicate that a social-contextual approach to tobacco control may be useful for narrowing a widening trajectory of smoking disparity for rural women. Interpersonal context, in particular, must be considered in the development of culturally targeted cessation interventions for Ohio Appalachian women.

Barriers to and facilitators of smoking cessation in pregnancy and following childbirth: literature review and qualitative study

BACKGROUND

Although many women stop smoking in pregnancy, others continue, causing harm to maternal and child health. Smoking behaviour is influenced by many factors, including the role of women's significant others (SOs) and support from health-care professionals (HPs).

OBJECTIVES

To enhance understanding of the barriers to, and facilitators of, smoking cessation and the feasibility and acceptability of interventions to reach and support pregnant women to stop smoking.

DESIGN

Four parts: (1) a description of interventions in the UK for smoking cessation in pregnancy; (2) three systematic reviews (syntheses) of qualitative research of women's, SOs' and HPs' views of smoking in pregnancy using meta-ethnography (interpretative approach for combining findings); (3) semistructured interviews with pregnant women, SOs and HPs, guided by the social-ecological framework (conceptualises behaviour as an outcome of individuals' interactions with environment); and (4) identification of new/improved interventions for future testing.

SETTING

Studies in reviews conducted in high-income countries. Qualitative research was conducted from October 2013 to December 2014 in two mixed urban/rural study sites: area A (Scotland) and area B (England).

PARTICIPANTS

Thirty-eight studies (1100 pregnant women) in 42 papers, nine studies (150 partners) in 14 papers and eight studies described in nine papers (190 HPs) included in reviews. Forty-one interviews with pregnant women, 32 interviews with pregnant women's SOs and 28 individual/group interviews with 48 HPs were conducted.

MAIN OUTCOME MEASURES

The perceived barriers to, and facilitators of, smoking cessation in pregnancy and the identification of potential new/modified interventions.

RESULTS

Syntheses identified smoking-related perceptions and experiences for pregnant women and SOs that were fluid and context dependent with the capacity to help or hinder smoking cessation. Themes were analysed in accordance with the social-ecological framework levels. From the analysis of the interviews, the themes that were central to cessation in pregnancy at an individual level, and that reflected the findings from the reviews, were perception of risk to baby, self-efficacy, influence of close relationships and smoking as a way of coping with stress. Overall, pregnant smokers were faced with more barriers than facilitators. At an interpersonal level, partners' emotional and practical support, willingness to change smoking behaviour and role of smoking within relationships were important. Across the review and interviews of HPs, education to enhance knowledge and confidence in delivering information about smoking in pregnancy and the centrality of the client relationship, protection of which could be a factor in downplaying risks, were important. HPs acknowledged that they could best assist by providing support and understanding, and access to effective interventions, including an opt-out referral pathway to Stop Smoking Services, routine carbon monoxide screening, behavioural support and access to pharmacotherapy. Additional themes at community, organisational and societal levels were also identified.

LIMITATIONS

Limitations include a design grounded in qualitative studies, difficulties recruiting SOs, and local service configurations and recruitment processes that potentially skewed the sample.

CONCLUSIONS

Perceptions and experiences of barriers to and facilitators of smoking cessation in pregnancy are fluid and context dependent. Effective interventions for smoking cessation in pregnancy should take account of the interplay between the individual, interpersonal and environmental aspects of women's lives.

FUTURE WORK

Research focus: removing barriers to support, improving HPs' capacity to offer accurate advice, and exploration of weight concerns and relapse prevention. Interventions focus: financial incentives, self-help and social network interventions.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013004170.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Older Māori understandings of alcohol use in Aotearoa/New Zealand

BACKGROUND

The predominant framing of indigenous people's alcohol use as problematic has resulted in narrow understandings of indigenous alcohol use in general. In particular, there has been little exploration of how Māori, those indigenous to Aotearoa/New Zealand, contextualise and understand their alcohol use. To build on current understandings of Māori alcohol use, this study explored the broader and socially shared meanings of alcohol use from the perspectives of older Māori.

METHODS

Hui (meeting/s) were held with five kaupapa whānau (groups with a common purpose) comprising older Māori (n = 19) who shared their perspectives on Māori alcohol use. Data were analysed using a master/counter discursive narrative analytical framework.

RESULTS

The results show that older Māori drew on a number of discursive strategies to construct three cultural narratives of Māori alcohol use. These were: 'Not all Māori are problem drinkers', 'There is good Māori alcohol use', and 'Alcohol is not the problem'. These narratives simultaneously supported and challenged the dominant narrative that problematises Māori alcohol use.

CONCLUSION

These findings can be used to inform future research to show Māori understandings of alcohol use. Such research will support the development of culturally responsive alcohol policy and health promotion initiatives aimed at addressing alcohol related issues among Māori and thereby improve Māori health and wellbeing.

A Novel Approach to Transforming Smoking Cessation Practice for Pregnant Aboriginal Women and Girls Living in the Pilbara

Tobacco smoking during pregnancy contributes to a range of adverse perinatal outcomes; but is a potentially modifiable behavior. In Australia Aboriginal and Torres Strait Islander women face a range of barriers that hinder; rather than support smoking cessation. Few smoking cessation programs consider the broader social determinants of women’s lives; the gendered nature of these or the complexities which impinge on behavior change in the presence of social and economic disadvantage and substantial individual and intergenerational trauma. Drawing on the salient gender and trauma-informed literature this paper describes the rationale underpinning formative research which will inform the design of a localized, culturally meaningful smoking cessation program for Aboriginal women living in the Hedland and Western Desert communities of the remote Pilbara region of Western Australia. We contend that a women-centered, trauma-informed approach to smoking cessation has much to offer those seeking to address this critical public health issue

Establishing Smoke-Free Homes in the Indigenous Populations of Australia, New Zealand, Canada and the United States: A Systematic Literature Review

A smoke-free home can have multiple benefits by reducing exposure to secondhand smoke (SHS), supporting quit attempts among active smokers, and discouraging adolescents from taking up smoking. The aim of this review was to summarize the literature on the establishment of smoke-free homes in Indigenous populations and identify the supporting influences and barriers, using the Social Cognitive Theory lens. A search of the Medline, CINAHL, Cochrane Collaboration and PyscINFO databases and manual searches of relevant peer-reviewed literature was completed, focusing on Indigenous populations in developed economies of North America and Oceania. Of 2567 articles identified, 15 studies were included. Ten studies included Indigenous participants only, and of these just three focused entirely on SHS in the home. Knowledge of the harms associated with SHS was the most common theme represented in all the studies. This knowledge fueled parents’ motivation to protect their children from SHS by establishing smoke-free homes. Individuals who approached implementation with confidence, coupled with clear communication about smoke-free home rules were more successful. Barriers included challenges for families with multiple smokers living in the same dwelling. There is limited research regarding managing smoking behaviors in the home among Indigenous populations, even though this approach is a successful catalyst for smoking prevention and cessation. Research to understand the influences that support the establishment of smoke-free homes is required for better-informed intervention studies.

Wula (Voices) of Aboriginal women on barriers to accepting smoking cessation support during pregnancy: Findings from a qualitative study

AIM

To gather Aboriginal women's stories of smoking and becoming pregnant to identify the barriers in accepting smoking cessation support during pregnancy.

METHODS

Qualitative data were collected through use of yarning methodology between August 2015 and January 2016 by an Aboriginal Researcher with experience in social and community services. A short on-line survey was used to collect quantitative data. Interviews only recorded the therapeutic yarning process, which ranged from 9 to 45min duration, averaging 30min. Audio-recorded interviews were transcribed and independently coded. A general inductive analysis was used to determine emergent themes.

RESULTS

Twenty Aboriginal women between 17-38 years of age, who were pregnant or recently given birth, living in the Hunter New England (HNE) area took part. Eleven women were still smoking; nine had quit. Most were highly aware of the implications of smoking for their babies. Major themes identified for accepting support were: ambivalence towards a need for support, health professional advice, reduction in smoking, and attitudes to Nicotine Replacement Therapy (NRT). Women reported being advised to cut down, rather than to quit; reducing consumption may be a barrier to accepting NRT. Women recommended enhanced clinical support and Aboriginal community engagement in cessation care.

DISCUSSION/CONCLUSIONS

Aboriginal women in the HNE area reported quitting or reducing their cigarette intake during pregnancy. Health Professionals working with Aboriginal women during pregnancy should give consistent messages to quit smoking completely, and offer increased, ongoing and extensive smoking cessation support to Aboriginal mothers. Clinical practices could partner with Aboriginal communities to support the delivery of smoking cessation services.

Chronological narratives from smoking initiation through to pregnancy of Indigenous Australian women: A qualitative study

OBJECTIVE

One in two Indigenous Australian pregnant women smoke, yet little is known about their trajectory of smoking. This study aimed to explore Aboriginal women's narratives from starting smoking through to pregnancy.

METHODS

A female Aboriginal Researcher conducted individual face-to-face interviews with 20 Aboriginal women from New South Wales, Australia. Recruitment, through Aboriginal services and community networks, continued until saturation was reached. Audio-recorded transcripts were independently open coded by two researchers, inductively analysed and reported using a three-dimensional structure of looking backwards, forwards, inwards, outwards and a sense of place, to elucidate the chronology of events, life stages, characters, environments, and turning points of the stories.

RESULTS

A chronology emerged from smoking initiation in childhood, coming of age, becoming pregnant, through to attempts at quitting, and relapse post-partum. Several new themes emerged: the role mothers play in women's smoking and quitting; the contribution of nausea to spontaneous quitting; depression as a barrier to quitting; and the hopes of women for their own and their children's future. The epiphany of pregnancy was a key turning point for many - including the interplay of successive pregnancies; and the intensity of expressed regret.

CONCLUSIONS

Aboriginal women report multiple influences in the progression of early smoking to pregnancy and beyond. Potential opportunities to intervene include: a) childhood, coming of age, pregnancy, post-natal, in-between births; b) key influencers; c) environments, and d) targeting concurrent substance use. Morning sickness appears to be a natural deterrent to continued smoking. Depression, and its relationship to smoking and quitting in Australian Indigenous pregnant women, requires further research.

Psychosocial interventions for supporting women to stop smoking in pregnancy

BACKGROUND

Tobacco smoking remains one of the few preventable factors associated with complications in pregnancy, and has serious long-term implications for women and babies. Smoking in pregnancy is decreasing in high-income countries, but is strongly associated with poverty and is increasing in low- to middle-income countries.

OBJECTIVES

To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes.

SEARCH METHODS

In this sixth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 November 2015), checked reference lists of retrieved studies and contacted trial authors.

SELECTION CRITERIA

Randomised controlled trials, cluster-randomised trials, and quasi-randomised controlled trials of psychosocial smoking cessation interventions during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and trial quality, and extracted data. Direct comparisons were conducted in RevMan, with meta-regression conducted in STATA 14.

MAIN RESULTS

The overall quality of evidence was moderate to high, with reductions in confidence due to imprecision and heterogeneity for some outcomes. One hundred and two trials with 120 intervention arms (studies) were included, with 88 trials (involving over 28,000 women) providing data on smoking abstinence in late pregnancy. Interventions were categorised as counselling, health education, feedback, incentives, social support, exercise and dissemination.In separate comparisons, there is high-quality evidence that counselling increased smoking cessation in late pregnancy compared with usual care (30 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.73) and less intensive interventions (18 studies; average RR 1.25, 95% CI 1.07 to 1.47). There was uncertainty whether counselling increased the chance of smoking cessation when provided as one component of a broader maternal health intervention or comparing one type of counselling with another. In studies comparing counselling and usual care (largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy. However, a clear effect was seen in smoking abstinence at zero to five months postpartum (11 studies; average RR 1.59, 95% CI 1.26 to 2.01) and 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), with a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77). In other comparisons, the effect was unclear for most secondary outcomes, but sample sizes were small.Evidence suggests a borderline effect of health education compared with usual care (five studies; average RR 1.59, 95% CI 0.99 to 2.55), but the quality was downgraded to moderate as the effect was unclear when compared with less intensive interventions (four studies; average RR 1.20, 95% CI 0.85 to 1.70), alternative interventions (one study; RR 1.88, 95% CI 0.19 to 18.60), or when smoking cessation health education was provided as one component of a broader maternal health intervention.There was evidence feedback increased smoking cessation when compared with usual care and provided in conjunction with other strategies, such as counselling (average RR 4.39, 95% CI 1.89 to 10.21), but the confidence in the quality of evidence was downgraded to moderate as this was based on only two studies and the effect was uncertain when feedback was compared to less intensive interventions (three studies; average RR 1.29, 95% CI 0.75 to 2.20).High-quality evidence suggests incentive-based interventions are effective when compared with an alternative (non-contingent incentive) intervention (four studies; RR 2.36, 95% CI 1.36 to 4.09). However pooled effects were not calculable for comparisons with usual care or less intensive interventions (substantial heterogeneity, I2 = 93%).High-quality evidence suggests the effect is unclear in social support interventions provided by peers (six studies; average RR 1.42, 95% CI 0.98 to 2.07), in a single trial of support provided by partners, or when social support for smoking cessation was provided as part of a broader intervention to improve maternal health.The effect was unclear in single interventions of exercise compared to usual care (RR 1.20, 95% CI 0.72 to 2.01) and dissemination of counselling (RR 1.63, 95% CI 0.62 to 4.32).Importantly, high-quality evidence from pooled results demonstrated that women who received psychosocial interventions had a 17% reduction in infants born with low birthweight, a significantly higher mean birthweight (mean difference (MD) 55.60 g, 95% CI 29.82 to 81.38 g higher) and a 22% reduction in neonatal intensive care admissions. However the difference in preterm births and stillbirths was unclear. There did not appear to be adverse psychological effects from the interventions.The intensity of support women received in both the intervention and comparison groups has increased over time, with higher-intensity interventions more likely to have higher-intensity comparisons, potentially explaining why no clear differences were seen with increasing intervention intensity in meta-regression analyses. Among meta-regression analyses: studies classified as having 'unclear' implementation and unequal baseline characteristics were less effective than other studies. There was no clear difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however there was uncertainty in the effectiveness of counselling in four dissemination trials where the focus on the intervention was at an organisational level. The pooled effects were similar in interventions provided for women classified as having predominantly low socio-economic status, compared to other women. The effect was significant in interventions among women from ethnic minority groups; however not among indigenous women. There were similar effect sizes in trials with biochemically validated smoking abstinence and those with self-reported abstinence. It was unclear whether incorporating use of self-help manuals or telephone support increased the effectiveness of interventions.

AUTHORS' CONCLUSIONS

Psychosocial interventions to support women to stop smoking in pregnancy can increase the proportion of women who stop smoking in late pregnancy and the proportion of infants born low birthweight. Counselling, feedback and incentives appear to be effective, however the characteristics and context of the interventions should be carefully considered. The effect of health education and social support is less clear. New trials have been published during the preparation of this review and will be included in the next update.

Oral health interventions in Australian Aboriginal communities: a review of the literature

Aboriginal Australians experience significant disparities in oral health with even poorer outcomes reported in rural and remote areas. The high rates of preventable dental disease in Aboriginal communities are a serious concern from a social standpoint and in terms of service provision and health care expenditure. In this review, primary research literature was comprehensively reviewed. Papers were selected if they reported designing or implementing an intervention or oral health programme specific to the needs of Aboriginal communities. Twenty-one publications fulfilled the inclusion criteria with 19 different interventions being described. Interventions were categorized using a classification adapted from the work of Whitehead (2002). The review identified interventions that aimed to reduce early childhood caries, increase services to remote communities, develop the role of Aboriginal health workers, improve oral health literacy, establish water fluoridation and provide periodontal therapy. Implementing successful oral health interventions in Aboriginal communities is a challenge that is compounded by the complex interplay between psychosocial and cultural determinants. Even interventions that follow a rigorous and consultative design have a high failure rate in Aboriginal communities if upstream determinants of health are not adequately understood and addressed.

Gender determinants of smoking practice in Indigenous communities: an exploratory study

Despite the need to urgently reduce smoking rates among Indigenous Australians, in order to close-the-gap in life expectancy, little is known regarding how this can be achieved. This study aimed to explore whether a focus on gender specific determinants of smoking among Indigenous Australians could be identified, thus providing a potentially novel approach to underpin future efforts at intervention. A qualitative research design was employed. Eighty-two participants, comprised of 43 Indigenous women (mean age 32.15, SD, 12.47) and 39 Indigenous men (mean age 34.91, SD, 11.26), participated in one of 12 focus groups held in metropolitan, regional and rural locations in South Australia. Facilitators prompted discussion in response to the question: 'What is it like being a smoker these days?' Two experienced coders assessed data for themes using Attride-Stirling's (2002) method of analysis. Two global themes emerged for men and women. The first theme, 'It's Harder to Smoke Nowadays', encompassed sub-themes capturing changed smoking practices in response to tobacco control strategies implemented in Australia. Sub-themes of 'smoking in secrecy' coupled with an 'awareness of the effects of passive smoking' were identified among women. Among men, sub-themes that depicted tension between 'a desire to be a role model' and 'guilt about smoking' emerged. The second theme, 'Push and Pull Factors', identified a range of gender specific determinants of smoking. While similar reasons for smoking ('pull factors') were identified in men and women (e.g. addiction, boredom, stress, pleasure, mood stabiliser), different 'push factors' (reasons for not wanting to smoke) emerged. For men, sport, fitness and children were identified as reasons for not wanting to smoke, whereas women identified factors such as respect for non-smokers, and body image concerns. The current findings suggest that there may be fundamental differences in the determinants of smoking (pull factors) as well as reasons for wanting to quit (push factors) between Indigenous men and women. A focus on interventions that target gender specific determinants, or motivators of smoking, offers a novel, and potentially efficacious approach to reduce smoking rates among Indigenous Australians.

Collective and negotiated design for a clinical trial addressing smoking cessation supports for Aboriginal and Torres Strait Islander mothers in NSW, SA and Qld – developing a pilot study

Tobacco smoking leads to one in five deaths of Aboriginal Australians and accounts for 17% of the reversible health gap. One in two Aboriginal women are reported to smoke during pregnancy, with no effective strategies currently available for health practitioners to utilise for supporting Aboriginal women. Aboriginal community participation in primary health research is crucial to implementing ethical research, with a clear benefit to the people and communities involved. However, currently there is little evidence on how Aboriginal programs and interventions are being developed in partnership with Aboriginal people and communities. ‘Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy’ aims to address the prevalence of smoking during pregnancy by enhancing health providers’ training in offering evidence-based smoking cessation care to Aboriginal mothers during pregnancy. This paper outlines the participatory research approach adopted for the developmental phase of the ‘ICAN QUIT in Pregnancy’ project developed in partnership with two Aboriginal Community-Controlled Health Services in NSW, and negotiation processes undertaken to implement a pilot intervention across NSW, SA and Qld.

Infant born with Robert's syndrome without prenatal care in a developing nation

Maternal and child well-being during pregnancy can be attributed to receiving optimal prenatal care. However, in developing nations, there are many barriers to receiving this. We present a primigravid female aged 29 years with severe abdominal pain. She was in active labour at 40 weeks and completely unaware of her pregnancy; hence, she did not receive any prenatal care. The baby was born with significant birth deformities that were consistent with Robert's syndrome. Although early detection could not preclude the development of this disorder, proper care would have facilitated in receiving genetic counselling and proper understanding of the prognosis. In this case, we discuss the various barriers to receiving prenatal care and measures taken for improvement in developing nations.

When There Is Not Enough Evidence and When Evidence Is Not Enough: An Australian Indigenous Smoking Policy Study

BACKGROUND

The Indigenous Tobacco Control Initiative and Tackling Indigenous Smoking Measure were both announced by the Australian Government at a time when its rhetoric around the importance of evidence-based policy making was strong. This article will (1) examine how the Rudd Government used evidence in Indigenous tobacco control policy making and (2) explore the facilitators of and barriers to the use of evidence.

METHODS

Data were collected through (1) a review of primary documents largely obtained under the Freedom of Information Act 1982 (Commonwealth of Australia) and (2) interviews with senior politicians, senior bureaucrats, government advisors, Indigenous health advocates, and academics. Through the Freedom of Information Act process, 24 previously undisclosed government documents relevant to the making of Indigenous tobacco control policies were identified. Interviewees (n = 31, response rate 62%) were identified through both purposive and snowball recruitment strategies. The Framework Analysis method was used to analyze documentary and interview data.

RESULTS

Government policy design was heavily influenced by the recommendations presented in government authored/commissioned literature reviews. Resulting policies were led by equivocal evidence for improved tobacco control outcomes among Indigenous Australians. Many of the cited studies had methodological limitations. In the absence of high-quality evidence, some policy makers supported policy recommendations that were perceived to be popular among the Indigenous community. Other policy makers recognized that there were barriers to accumulating rigorous, generalizable evidence; in the absence of such evidence, the policy makers considered that the "need for action" could be combined with the "need for research" by introducing innovative strategies and evaluating them.

DISCUSSION

Despite the absence of high-quality evidence, the formulation and adoption of Indigenous tobacco policy was neither irrational nor reckless. The decision to adopt an innovate and evaluate strategy was justifiable given (a) the potential for the gap between Indigenous and non-Indigenous health outcomes to worsen in the absence of an imminent policy response; (b) the existence of circumstances, which made it difficult to obtain high-quality evidence to guide policy; and (c) the need for policy solutions to reflect community preferences, given sociohistorical sensitivities.

Ready, set, go: a cross-sectional survey to understand priorities and preferences for multiple health behaviour change in a highly disadvantaged group

Background

Socially disadvantaged groups, such as Aboriginal Australians, tend to have a high prevalence of multiple lifestyle risk factors, increasing the risk of disease and underscoring the need for services to address multiple health behaviours. The aims of this study were to explore, among a socially disadvantaged group of people attending an Aboriginal Community Controlled Health Service (ACCHS): a) readiness to change health behaviours; b) acceptability of addressing multiple risk factors sequentially or simultaneously; and c) preferred types of support services.

Methods

People attending an ACCHS in regional New South Wales (NSW) completed a touchscreen survey while waiting for their appointment. The survey assessed participant health risk status, which health risks they would like to change, whether they preferred multiple health changes to be made together or separately, and the types of support they would use.

Results

Of the 211 participants who completed the survey, 94 % reported multiple (two or more) health risks. There was a high willingness to change, with 69 % of current smokers wanting to cut down or quit, 51 % of overweight or obese participants wanting to lose weight and 44 % of those using drugs in the last 12 months wanting to stop or cut down. Of participants who wanted to make more than one health change, over half would be willing to make simultaneous or over-lapping health changes. The most popular types of support were help from a doctor or Health Worker and seeing a specialist, with less than a quarter of participants preferring telephone or electronic (internet or smart phone) forms of assistance. The importance of involving family members was also identified.

Conclusions

Strategies addressing multiple health behaviour changes are likely to be acceptable for people attending an ACCHS, but may need to allow flexibility in the choice of initial target behaviour, timing of changes, and the format of support provided.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1701-2) contains supplementary material, which is available to authorized users.

Maternal smoking in pregnancy and its influence on childhood asthma

Maternal smoking in pregnancy (MSP) is a large modifiable risk factor for pregnancy related mortality and morbidity and also the most important known modifiable risk factor for asthma. This review summarises the effects of MSP throughout infancy, childhood and adolescence with regards to asthma (development and severity). Firstly, the direct damage caused by nicotine on fetal lung development, fetal growth and neuronal differentiation is discussed, as well as the indirect effects of nicotine on placental functioning. Secondly, the effects of MSP on later immune functioning resulting in increased infection rate are summarised and details are given on the effects of MSP modulating airway hyperreactivity, reducing lung function and therefore increasing asthma morbidity. Furthermore, epigenetic effects are increasingly being recognised. These can also result in transgenerational detrimental effects induced by cigarette smoke. In summary, the causal relationship between MSP and asthma development is well documented and presents a major health problem for generations to come. The high prevalence of MSP is alarming and epigenetic effects of nicotine on immune functioning potentiate this danger. A considerable part of the increase in asthma prevalence worldwide is due to MSP.

Psychosocial Characteristics Associated with Both Antiretroviral Therapy Adherence and Risk Behaviors in Women Living with HIV

The purpose of this study was to identify key psychosocial characteristics of HIV-infected women who exhibit different levels of both ART adherence and risk behaviors. We analyzed baseline data from 193 predominately African American HIV-infected women participating in a behavioral clinical trial. Women were categorized into high/low groups based on levels of adherence and risky behaviors. There was a significant interaction effect for internal motivation for adherence. Women at high risk for poor health and transmitting HIV (low adherence/high risk group) had the lowest levels of internal motivation and also reported more difficult life circumstances. Gender roles, caretaking and reliance on men for economic and other support may promote external versus internal motivation as well as riskier behaviors in this group. The highest levels of internal motivation were found in those with High Adherence/High Risk behaviors. This group was highly knowledgeable about HIV and had the lowest VL. Compared to others, this group seems to tolerate risky behaviors given their high level of adherence. Adherence and risk reduction behaviors are key to individual and public health. Motivation and risk compensation should be addressed when providing interventions to women living with HIV.