Barriers and enablers to addressing smoking, nutrition, alcohol consumption, physical activity and gestational weight gain (SNAP-W) as part of antenatal care: A mixed methods systematic review

BACKGROUND

International clinical guidelines recommend that smoking, nutrition, alcohol consumption, physical activity and gestational weight gain (SNAP-W) be addressed as part of routine antenatal care throughout pregnancy. However, guideline recommendations are poorly implemented, and few antenatal care recipients routinely receive the recommended care. There is a need to establish the determinants (barriers and enablers) to care delivery to inform strategies to improve implementation. This systematic review aimed to synthesize qualitative and quantitative evidence of the barriers and enablers to the routine delivery of antenatal care targeting SNAP-W health risks.

METHODS

A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Seven databases were searched for relevant studies published between January 2001 and November 2023. Study findings were coded and analysed according to the domains of the Theoretical Domains Framework (TDF).

RESULTS

Forty-nine studies were included in the review, 27 qualitative studies and 22 quantitative studies. The studies were conducted in 14 countries. Data were collected from 7146 antenatal care providers (midwives, Aboriginal health workers, obstetricians, medical officers, general practitioners) and 352 barriers and enablers were identified. Across all SNAP-W health risk and antenatal care provider groups, the predominant TDF domain was 'environmental context and resources', identified in 96% of studies. Barriers within this domain included insufficient time, limited access to and quality of resources, and limited organisational supports. 'Beliefs about consequences' was the second most common TDF domain, reported in 67% of studies, particularly studies of care related to alcohol use, nutrition/ physical activity/ gestational weight gain and those involving midwives, multidisciplinary practitioners and general practitioners. 'Optimism' was the second most common TDF domain for studies of smoking-related care and involving obstetricians, gynaecologists, and other mixed medical professions.

CONCLUSIONS

It is critical that determinants related to environmental context and resources including time, resources and organisational supports are considered in the development of strategies to support the implementation of recommended antenatal care related to SNAP-W risks. Strategies addressing clinician beliefs about consequences and optimism may also be needed to support the implementation of care related to specific health behaviours and by specific antenatal care provider groups.

REGISTRATION

The review protocol was prospectively registered with Prospero: CRD42022353084; 22 October 2022.

The effectiveness of implementation strategies in improving preconception and antenatal preventive care: a systematic review

BACKGROUND

Clinical guideline recommendations for addressing modifiable risk factors are not routinely implemented into preconception and antenatal care. This review assessed the effectiveness of implementation strategies in improving health professional provision of preconception and antenatal care addressing tobacco smoking, weight management and alcohol consumption.

METHODS

A systematic review of randomised and non-randomised studies with a parallel comparison group was conducted. Eligible studies used implementation strategy/ies targeted at health professionals to improve at least one element of preconception and/or antenatal care (smoking: ask, advise, assess, assist, arrange; weight/alcohol: assess, advise, refer) compared to usual practice/control or alternative strategies. Eligible studies were identified via CENTRAL, MEDLINE, EMBASE, Maternity and Infant Care, CINAHL and other sources. Random-effects meta-analyses were conducted where appropriate, with other findings summarised using the direction of effect. The certainty of the pooled evidence was assessed using the GRADE approach.

RESULTS

Fourteen studies were included in the review. Thirteen were in the antenatal period and 12 tested multiple implementation strategies (median: three). Meta-analyses of RCTs found that implementation strategies compared to usual practice/control probably increase asking (OR: 2.52; 95% CI: 1.13, 5.59; 3 studies; moderate-certainty evidence) and advising (OR: 4.32; 95% CI: 3.06, 6.11; 4 studies; moderate-certainty evidence) about smoking and assessing weight gain (OR: 57.56; 95% CI: 41.78, 79.29; 2 studies; moderate-certainty evidence), and may increase assessing (OR: 2.55; 95% CI: 0.24, 27.06; 2 studies; low-certainty evidence), assisting (OR: 6.34; 95% CI: 1.51, 26.63; 3 studies; low-certainty evidence) and arranging support (OR: 3.55; 95% CI: 0.50, 25.34; 2 studies; low-certainty evidence) for smoking. The true effect of implementation strategies in increasing advice about weight gain (OR: 3.37; 95% CI: 2.34, 4.84; 2 non-randomised studies; very low-certainty evidence) and alcohol consumption (OR: 10.36; 95% CI: 2.37, 41.20; 2 non-randomised studies; very low-certainty evidence) is uncertain due to the quality of evidence to date.

CONCLUSIONS

Review findings provide some evidence to support the effectiveness of implementation strategies in improving health professional delivery of antenatal care addressing smoking and weight management. Rigorous research is needed to build certainty in the evidence for improving alcohol and weight gain advice, and in preconception care.

TRIAL REGISTRATION

PROSPERO-CRD42019131691.

Practising pharmacists want more nutrition education

BACKGROUND AND PURPOSE

Although pharmacists are first and foremost medication specialists and suppliers, in Australia they are also ideally positioned within the healthcare setting to encourage and support positive lifestyle choices in the community. Little has been done to assess their nutrition knowledge in over 20 years. We aimed to explore pharmacists' nutrition knowledge and associated practice and to subsequently develop and evaluate a short course to fill identified gaps.

EDUCATIONAL ACTIVITY AND SETTING

The General Nutrition Knowledge Questionnaire was revised for testing nutrition knowledge in the pharmacy setting. Once validated, the questionnaire was distributed to pharmacists using social/professional media advertising. A short course was then developed, and its effectiveness assessed on final-year pharmacy students.

FINDINGS

Pharmacists' (N = 258) mean score was 89.9 out of 121 (SD = 10.6) with significant variation. Nutrition education provision in practice was provided inconsistently and was associated with how strongly participants rated their own knowledge. Most pharmacists (95.7%) agreed they are well-placed to assist in disease burden reduction through nutrition education; however, most (98.4%) felt their knowledge needed improvement. The short course was well received by participants, deemed to be appropriate in context, and resulted in a median improvement in matched scores of 14.7% (P < .001) with no significant decline in knowledge when reassessed three weeks later (P = .383).

SUMMARY

Pharmacists' nutrition knowledge and practice was variable. Further education can improve knowledge without significant time outlay and is likely to improve associated counselling practices.

The role of the pharmacist in contraception and pre-pregnancy management for women with diabetes: a study of patient and pharmacist perspectives

Objectives

Women with diabetes are at increased risk of adverse pregnancy outcomes compared to women with gestational diabetes (GDM) or no diabetes. Pregnancy outcomes are improved by specialist pre-pregnancy care. We aimed to explore pharmacists’ and women with diabetes’ perceptions of the roles and barriers to pharmacist participation in a diabetes contraception and pre-pregnancy program in South-Western Sydney (SWS).

Methods

The Diabetes Contraception and Pre-pregnancy Program (DCAPP) aims to reduce adverse pregnancy outcomes among women with diabetes. This includes awareness raising among, and through, pharmacists. Surveys to explore pharmacists’ roles in contraception and pre-pregnancy management (CPPM) were completed by SWS pharmacists and women with diabetes from diabetes clinics aged 18–50 years. Survey themes were then discussed in interviews and focus groups with pharmacists across Australia. Thematic analysis of transcripts was undertaken.

Key findings

Pharmacists were seen to have a role in diabetes health promotion, information distribution and referral to pre-pregnancy clinics. Pharmacists and women recognised the need for increased knowledge and educational materials about CPPM and effective awareness and coordination of CPPM services. Some pharmacists recognised deficits in their knowledge regarding diabetes in pregnancy, including CPPM and differences to GDM. Barriers to pharmacists’ involvement in CPPM included difficulty identifying applicable women and reluctance to initiate pregnancy planning and contraception conversations, often due to language and cultural barriers.

Conclusions

Pharmacists and women with diabetes see an important role for pharmacists in CPPM. Co-designed diabetes training for pharmacists and increased communication about DCAPP were seen important for ongoing implementation.

Pregnant Women Have Poor Carbohydrate Knowledge and Do Not Receive Adequate Nutrition Education

OBJECTIVES

In order to manage blood glucose levels in pregnancy, women need to know what and how much to eat, particularly for foods containing carbohydrate. The aim was to assess pregnant women's carbohydrate and standard serve size knowledge and examine whether health professionals provided nutrition education.

METHODS

Between July 2017 and April 2018 Australian pregnant women were recruited to complete an online survey, including a modified PedCarbQuiz carbohydrate knowledge questionnaire and an online buffet, where they selected images equivalent to one Australian Guide to Healthy Eating (AGHE) standard serve size.

RESULTS

186 pregnant women (mean age 30.9 years, SD = 4.7 years) 12-22 weeks gestation completed the survey. Participants achieved a median score of 27/36 for identification of carbohydrate-containing foods and a median score of 1/12 (range 0-11) for identification of grams of carbohydrate in specific portions. Participants achieved a median score of 14/22 (range 4-19) for identification of one AGHE standard serve of 11 carbohydrate-containing foods. Less than half (n = 92, 49.5%) received nutrition education from health professionals.

CONCLUSIONS FOR PRACTICE

Pregnant women had sub-optimal carbohydrate knowledge. This could contribute to impaired blood glucose concentrations and risk of adverse health outcomes in pregnancy. Opportunities for pregnant women to access nutrition advice from health professionals should be explored.

Self-Reported Nutrition Education Received by Australian Midwives before and after Registration

Educating midwives to provide nutrition advice is essential. Limited research focuses on midwives' nutrition education. This paper explores self-reported nutrition education received by Australian midwives before and after registration. It draws on quantitative and qualitative data from a larger online survey conducted with the members of the Australian College of Midwives (response rate = 6.9%, n = 329). Descriptive and content analyses were used. Of the midwives, 79.3% (n = 261) reported receiving some nutrition education during, before, and/or after registration. However, some described this coverage as limited. It lacked sufficient focus on topics such as weight management, nutrition assessment, and nutrition for vulnerable groups. Continuing education often occurred through personal initiatives, such as the midwife enrolling in external courses or exploring issues on the Internet and with colleagues. The majority of participants indicated a need for increased nutrition education (94.2%, n = 310) and guidelines tailored for them to provide nutrition advice (87.8%, n = 289). Australian midwives may not be receiving adequate nutrition education to provide nutrition advice. Inclusion of evidence-based nutrition components in midwifery education and regular updates for practising midwives focusing on challenging nutrition issues is required to ensure that they are supported in this important role.

A national mailed survey exploring weight management services across Australian community pharmacies

This study investigated pharmacists' and pharmacy assistants' current weight management recommendations to consumers across Australian community pharmacies using a mailed questionnaire. Two questionnaires were developed, one for pharmacists and one for pharmacy assistants, each divided into five sections. One pharmacist and pharmacy assistant questionnaire were mailed in November 2011 to a systematic sample of 3000 pharmacies across Australia for one pharmacist and pharmacy assistant each to complete. A total of 537 pharmacist and 403 pharmacy assistant responses, from 880 different pharmacies, were received. Overall 94.5% (n = 832/880) of associated pharmacies stocked weight loss products and 48.2% (n = 424/880) offered a weight management program. Both pharmacists and pharmacy assistants felt that the development of pharmacy-specific educational resources and additional training would help improve their ability to provide weight management services. Australian pharmacists and pharmacy assistants currently appear to be providing weight management services to consumers; however, not all their recommendations are evidence based. The need for additional training for pharmacy staff in areas identified as lacking and the development of pharmacy weight management educational resources needs to be addressed.

Employing the nominal group technique to explore the views of pharmacists, pharmacy assistants and women on community pharmacy weight management services and educational resources†

Objectives

The objectives of this study were to investigate how pharmacists, pharmacy assistants and women feel about community pharmacy involvement in weight management, and to identify what pharmacists, pharmacy assistants and women want in weight management educational resources.

Methods

Three homogenous and one heterogeneous nominal group (NG) sessions of up to 120-min duration were conducted with nine women, ten pharmacists and eight pharmacy assistants. The NG technique was used to conduct each session to determine the most important issues that should be considered surrounding community pharmacy weight management services and development of any educational resources. The heterogeneous NG session was used to finalise what women, pharmacists and pharmacy assistants want in educational resources.

Key findings

Overall, pharmacists, pharmacy assistants and women believe that pharmacy staff have an important role in the management of overweight and obesity because of their accessibility, trust and the availability of products in pharmacy. Regarding the most suitable healthcare professional(s) to treat overweight and obesity, the majority of participants believed that no one member of the healthcare team was most suitable and that overweight and obesity needs to be treated by a multidisciplinary team. The importance of having weight management educational resources for pharmacy staff and women that come from trustworthy resources without financial gain or commercialisation was also emphasised.

Conclusion

Pharmacists, pharmacy assistants and women feel that community pharmacies have a definite role to play in weight management. Pharmacy-specific weight management educational resources that are readily available to pharmacy staff and women are highly desirable.

Nutrition advice during pregnancy: do women receive it and can health professionals provide it?

A healthy diet during pregnancy is essential for normal growth and development of the foetus. Pregnant women may obtain nutrition information from a number of sources but evidence regarding the adequacy and extent of this information is sparse. A systematic literature review was conducted to identify sources of nutrition information accessed by pregnant women, their perceived needs for nutrition education, the perceptions of healthcare providers about nutrition education in pregnancy, and to assess the effectiveness of public health programs that aim to improve nutritional practices. The Scopus data base was searched during January, 2013 and in February 2014 to access both qualitative and quantitative studies published between 2002 and 2014 which focused on healthy pregnant women and their healthcare providers in developed countries. Articles were excluded if they focused on the needs of women with medical conditions, including obesity, gestational diabetes or malnutrition. Of 506 articles identified by the search terms, 25 articles were deemed to be eligible for inclusion. Generally, women were not receiving adequate nutrition education during pregnancy. Although healthcare practitioners perceived nutrition education to be important, barriers to providing education to clients included lack of time, lack of resources and lack of relevant training. Further well designed studies are needed to identify the most effective nutrition education strategies to improve nutrition knowledge and dietary behaviours for women during antenatal care.

Mothers' perceptions of primary health-care providers: thematic analysis of responses to open-ended survey questions

General practitioners and maternal, child and family health nurses have a central role in postpartum primary health care for women and their infants. Positive client-provider relationships are particularly important for women experiencing mental health problems or unsettled infant behaviour. However, little is known about their experiences of postnatal primary health care. The study aimed to describe views of postnatal primary health care among women completing a residential early parenting programme and to identify potential strategies to enhance provider-patient interactions. Participants (n=138) were women admitted with their infants to a private or a public early parenting service in Melbourne, Australia. Women completed a detailed self-report survey, including open-ended questions about experiences of primary health-care services, and a structured psychiatric interview to diagnose anxiety and depression. Survey responses were analysed thematically. Womens' experiences of primary health care were influenced by their perceptions of provider competence and the quality of interactions. While similar positive characteristics of doctor and nurse care were valued, medical and nursing practices were judged in different ways. Women described GPs who listened, understood and were thorough as providing good care, and maternal, child and family health nurses were valued for providing support, advice and encouragement. Threats to therapeutic relationships with doctors included feeling rushed during consultations, believing that GPs were not mental health-care providers and the clinician not being 'good' with the infant; with nurses, problems included feeling judged or given advice that was inconsistent or lacked an evidence-base. Postpartum primary health care will be improved by unhurried consultations, empathic recognition, encouragement, evidence-informed guidance and absence of criticism.

Medicine use and safety while breastfeeding: investigating the perspectives of community pharmacists in Australia

Consumers and health professionals rely on community pharmacists for accurate information about the safety of medicines. Many breastfeeding women require medications, yet we know little about the advice provided to them by pharmacists in Australia. The aim of this study therefore was to investigate the perspectives of community pharmacists in Australia on medication use and safety in breastfeeding using a postal survey of a national random sample of 1166 community pharmacies in 2011. One hundred and seventy-six pharmacists responded (51% female). Of the 52% of participants with children, many (70%) had a total breastfeeding duration (self or partner) of 27 weeks or more. The majority (92%) were confident about supplying or counselling on medication during breastfeeding. The most commonly used resources were drug company information, Australian Medicines Handbook and the Royal Women's Pregnancy and Breastfeeding Medicine Guide. Most (80%) believed the available information to be adequate and 86% thought it accessible. Over one-third were unaware that ibuprofen and metronidazole are compatible with breastfeeding. Most (80%) were able to name at least one medicine that may decrease milk supply. We found that community pharmacists discuss medicine use in lactation and are confident of their ability to do so; however, their knowledge may be variable.

Experiences of community pharmacists advising pregnant women

BACKGROUND

Recent studies have shown that pharmacists provide healthcare advice to pregnant women, and that they can play an important role in maternal care. However, pharmacists have faced challenges in advising mothers and coordinating with physicians.

OBJECTIVE

To explore the experiences of community pharmacists in advising pregnant women at Lithuanian community pharmacies.

SETTING

Community pharmacies in Lithuania.

METHODS

Community pharmacists (n = 27) were recruited for semistructured face-to-face interviews from June 2012 to March 2013. A qualitative and descriptive study based on the content analysis approach was used for data collection and analysis.

MAIN OUTCOME MEASURE

Thematic coding of Lithuanian community pharmacist interview content.

RESULTS

Three main areas emerged: topics of advice-giving, provision of information, and barriers to advice-giving. The question of whether to interact with the physician connected to all of these areas. Pharmacists described different practices about the advice they gave and how they gave it. Lack of knowledge and skills, both about pregnancy and about patient-physician-pharmacist interaction, were a clear barrier to care for pregnant women in community pharmacies.

CONCLUSION

Respondents were comfortable giving advice in clear situations, and found it challenging to do so otherwise. Improving the physician-pharmacist-patient communication environment and providing education and training programmes for pharmacists is necessary to reduce stress and to overcome barriers in advising pregnant women.

Exploring weight management recommendations across Australian community pharmacies using case vignettes

With the increase in the overweight and obese population, it is critical that pharmacy staff are able to provide weight management advice to women at different stages of their life. This study utilized case vignettes to identify pharmacists' and pharmacy assistants' current weight management recommendations to women of different ages, life stages and co-morbidities. A total of 537 pharmacist and 403 pharmacy assistant responses were received. In the case of the pre-pregnancy vignette, only 57% (46/80) of pharmacy assistants were able to correctly identify a woman's weight category based on her body mass index, which was significantly fewer than 86% (86/108) of pharmacists (P < 0.001). In the pregnancy vignette, both pharmacists and pharmacy assistants were able to identify the risks of using a herbal weight loss medication in pregnancy. The need for a 'multi-disciplinary team approach' was seen in the menopause case vignette with pharmacists, highlighting the need for the involvement of other health care professionals for successful weight loss outcomes. Australian pharmacists and pharmacy assistants are currently providing weight management services to their consumers, however, not all of their recommendations are evidence-based. There is a need for pharmacy weight management educational resources to be developed and implemented across community pharmacies.

Comparing women pharmacy consumers' experiences with weight loss treatment in Victoria and Nottingham: a cross-sectional study

BACKGROUND

There has been a recent increase in weight management services available in pharmacies across Australia and England. The aim of this study was to determine the following between women in Victoria and Nottingham: similarities and differences of what weight management options are preferred by women pharmacy consumers; how they feel about pharmacists providing advice in this area; and what they desire in a weight management program.

METHOD

Women pharmacy consumers were randomly approached by a researcher in community pharmacies in Victoria and Nottingham and asked to complete a questionnaire regarding their own weight management experiences. The questionnaire was self-completed or researcher-administered and was comprised of four main sections that focused on the participant's general health, previous weight loss experiences, their ideal weight management program and their demographics. Data was entered in SPSS 19 and logistic regression was used to identify any differences in weight loss experiences between women.

RESULTS

The participant rates were high: 86% (n = 395/460) in Victoria and 98% in Nottingham (n = 215/220). Overall, women in Victoria and Nottingham were similar with comparable demographics. Approximately 50% (250/507) of women were in the overweight or obese body mass index category, with over 70% (n = 436/610) of women having attempted to lose weight in the past. The majority of women (n = 334/436) felt comfortable receiving advice from pharmacists. In the logistic regression analysis women in Nottingham were found to be significantly less likely to have utilised a pharmacy weight management program in the last five years (OR: 0.23 CI: 0.08, 0.63) and were significantly less likely to want an ideal weight management program located in a pharmacy (OR: 0.49 CI: 0.30, 0.82) compared to women in Victoria. No significant associations between location and feeling comfortable with a pharmacist advising on weight loss or wanting a pharmacist in an ideal weight management program were seen.

CONCLUSION

Results from this study have provided information on possible ideal pharmacy weight management programs in both Victoria and Nottingham. Although differences were seen between the two populations, similarities between ideal weight management programs and comfort level with pharmacist interaction were noted.