Opportunities Missed: A Cross-Sectional Survey of the Provision of Smoking Cessation Care to Pregnant Women by Australian General Practitioners and Obstetricians

"It's a big conversation": Views of service personnel on systemic barriers to preventing smoking relapse among pregnant and postpartum Aboriginal and Torres Strait Islander women - A qualitative study

BACKGROUND

Providing smoking cessation care has not successfully prevented women who quit smoking during pregnancy from relapsing due to multi-level barriers.

AIM

This paper explores systemic barriers to providing smoking cessation care, focusing on relapse prevention among pregnant and postpartum Aboriginal and Torres Strait Islander women (hereafter Aboriginal).

METHODS

Twenty-six interviews were conducted between October 2020 and July 2021 with health professionals, health promotion workers and managers working in Aboriginal smoking cessation across six Australian states and territories. Data were thematically analysed.

FINDINGS

Themes emerging from the data included: (a) limited time, competing priorities and shortage of health professionals; (b) a need for more knowledge and skills for health professionals; (c) influences of funding allocations and models of smoking cessation care; (d) lack of relevance of anti-tobacco messages to pregnancy and postpartum relapse; and (e) ways forward. Several barriers emerged from policies influencing access to resources and approaches to smoking cessation care for Aboriginal women. Individual-level maternal smoking cessation care provision was often under-resourced and time-constrained to adequately meet Aboriginal women's needs. Identified needs for health professionals included more time, knowledge and skills, better cultural awareness for non-Indigenous health professionals, and salient anti-tobacco messages for pregnant women related to long-term cessation.

CONCLUSION

To drive smoking cessation in pregnant and postpartum Aboriginal women, we recommend adequately reimbursing midwives and Aboriginal Health Workers/Professionals to allow them to provide intensive support, build confidence in Quitline, continue health professionals' capacity-building and allocate consistent funding to initiatives that have been efficacious with Aboriginal women.

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.

Effect of a Best-Practice Alert on the Rate of Smoking Cessation among Pregnant Women

OBJECTIVE

This study aimed to determine if a best-practice alert (BPA) implementation increases the rate of smoking cessation during pregnancy and affects pregnancy outcomes associated with smoking.

STUDY DESIGN

This was a pretest-posttest study design where a BPA was added to electronic medical records (EMR) of pregnant persons who reported active smoking. The BPA provided the 5A's method to conduct counseling on smoking cessation. The rates of smoking cessation during pregnancy were compared 1.5 years before and after implementation of the BPA. Secondary outcomes examined whether counseling on smoking cessation was done, the number of the counseling sessions during pregnancy, and obstetric outcomes associated with maternal smoking.

RESULTS

After implementation of the BPA, the rate of smoking cessation in pregnancy increased from 17.5% prior to BPA implementation to 54.9% after BPA implementation (p < 0.001). The rate of counseling on smoking cessation increased from 66.6% prior to BPA implementation to 95.6% after BPA implementation, with an increase noted also in the number of smoking cessation counseling sessions. In multivariate analyses, after controlling for maternal demographic and clinical factors, BPA implementation was significantly associated with higher rates of smoking cessation (adjusted odds ratio [aOR]: 3.44, 95% confidence interval [CI]: 2.17-5.51), higher rates of documented smoking cessation counseling in the EMR (aOR: 12.44, 95% CI: 6.06-25.64), and higher odds of conducting the counseling more than once (aOR: 6.90 95% CI: 4.45-10.88).

CONCLUSION

The rate of smoking cessation and number of times pregnant persons were counseled increased after implementation of a BPA. The BPA could be a useful EMR tool to increase smoking cessation rates during pregnancy.

KEY POINTS

· Smoking during pregnancy is a maternal and fetal concern.. · Prenatal care offers the chance to address smoking.. · BPA increases rates of smoking counseling and cessation..

Protocol for the process evaluation of an intervention to improve antenatal smoking cessation support (MOHMQuit) in maternity services in New South Wales, Australia

INTRODUCTION

Smoking cessation in pregnancy remains a public health priority. Our team used the Behaviour Change Wheel to develop the Midwives and Obstetricians Helping Mothers to Quit smoking (MOHMQuit) intervention with health system, leader (including managers and educators) and clinician components. MOHMQuit addresses a critical evidence to practice gap in the provision of smoking cessation support in antenatal care. It involves nine maternity services in New South Wales in a cluster randomised stepped-wedge controlled trial of effectiveness. This paper describes the design and rationale for the process evaluation of MOHMQuit. The process evaluation aims to assess to what extent and how MOHMQuit is being implemented (acceptability; adoption/uptake; appropriateness; feasibility; fidelity; penetration and sustainability), and the context in which it is implemented, in order to support further refinement of MOHMQuit throughout the trial, and aid understanding and interpretation of the results of the trial.

METHODS AND ANALYSIS

The process evaluation is an integral part of the stepped-wedge trial. Its design is underpinned by implementation science frameworks and adopts a mixed methods approach. Quantitative evidence from participating leaders and clinicians in our study will be used to produce individual and site-level descriptive statistics. Qualitative evidence of leaders' perceptions about the implementation will be collected using semistructured interviews and will be analysed descriptively within-site and thematically across the dataset. The process evaluation will also use publicly available data and observations from the research team implementing MOHMQuit, for example, training logs. These data will be synthesised to provide site-level as well as individual-level implementation outcomes.

ETHICS AND DISSEMINATION

The study received ethical approval from the Population Health Services Research Ethics Committee for NSW, Australia (Reference 2021/ETH00887). Results will be communicated via the study's steering committee and will also be published in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

Australian New Zealand Trials Registry ACTRN12622000167763. https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12622000167763.

Factors associated with the implementation of the 5As model of smoking cessation support during pregnancy: A scoping review

INTRODUCTION

The prevalence of smoking among pregnant women is the highest in the European region, making smoking cessation a public health priority. In order to address this, pregnant smokers need to be better supported by their healthcare professionals in their attempts to quit smoking. The 5As model, which is a psychosocial intervention, seems to be effective in this specific population. The objective of this review is to identify the factors that act as barriers or facilitators to the implementation of the 5As model within prenatal practices.

METHODS

We conducted a scoping review of the literature on PubMed and Scopus databases, using the terms: 'smoking cessation', 'pregnan*', and ('5A' or '5As'). The identified factors were categorized using a theoretical framework of The European Observatory on Health Systems and Policies.

RESULTS

Among the 43 articles identified in the databases, 13 articles were included in this review. In total, we identified 48 factors. When necessary, we grouped them together, resulting in 12 sub-categories, which in turn were grouped into 9 categories. Those 9 categories were then classified into the 3 levels of the theoretical framework: the clinical level (motivation), the organizational level (healthcare pathway), and the health system level (political environment).

CONCLUSIONS

The factors identified are varied and numerous and are involved in each level of the theoretical framework.

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.

Smoking cessation care during pregnancy: A qualitative exploration of midwives' challenging role

PROBLEM

The majority of South Australian pregnant women who smoke do not quit during pregnancy. Additionally, the prevalence of smoking is higher among pregnant women living in socially disadvantaged areas.

BACKGROUND

Understanding challenges in midwives' provision of smoking cessation care can elucidate opportunities to facilitate women's smoking cessation.

AIM

We aimed to understand midwives' perspectives on current practices, perceived barriers and facilitators to delivery of smoking cessation care, and potential improvements to models of smoking cessation care.

METHODS

An exploratory qualitative research methodology and thematic analysis was used to understand the perspectives of midwives in five focus groups.

FINDINGS

Four themes were generated from the data on how midwives perceived their ability to provide smoking cessation care: Tensions between providing smoking cessation care and maternal care; Organisational barriers in the delivery of smoking cessation care; Scepticism and doubt in the provision of smoking cessation care; and Opportunities to enable midwives' ability to provide smoking cessation care.

DISCUSSION

A combination of interpersonal, organisational and individual barriers impeded on midwives' capacities to approach, follow-up and prioritise smoking cessation care. Working with women living with disadvantage and high rates of smoking, the midwife's role was challenging as it balanced delivering smoking cessation care without jeopardising antenatal care.

CONCLUSION

Providing midwives with resources and skills may alleviate the sense of futility that surrounds smoking cessation care. Provision of routine training and education could also improve understandings of the current practice guidelines.

The MOHMQuit (Midwives and Obstetricians Helping Mothers to Quit Smoking) Trial: protocol for a stepped-wedge implementation trial to improve best practice smoking cessation support in public antenatal care services

BACKGROUND

Smoking during pregnancy is the most important preventable cause of adverse pregnancy outcomes, yet smoking cessation support (SCS) is inconsistently provided. The MOMHQUIT intervention was developed to address this evidence-practice gap, using the Behaviour Change Wheel method by mapping barriers to intervention strategies. MOHMQuit includes systems, leadership and clinician elements. This implementation trial will determine the effectiveness and cost-effectiveness of MOHMQuit in improving smoking cessation rates in pregnant women in public maternity care services in Australia; test the mechanisms of action of the intervention strategies; and examine implementation outcomes.

METHODS

A stepped-wedge cluster-randomised design will be used. Implementation of MOHMQuit will include reinforcing leadership investment in SCS as a clinical priority, strengthening maternity care clinicians' knowledge, skills, confidence and attitudes towards the provision of SCS, and clinicians' documentation of guideline-recommended SCS provided during antenatal care. Approximately, 4000 women who report smoking during pregnancy will be recruited across nine sites. The intervention and its implementation will be evaluated using a mixed methods approach. The primary outcome will be 7-day point prevalence abstinence at the end of pregnancy, among pregnant smokers, verified by salivary cotinine testing. Continuous data collection from electronic medical records and telephone interviews with postpartum women will occur throughout 32 months of the trial to assess changes in cessation rates reported by women, and SCS documented by clinicians and reported by women. Data collection to assess changes in clinicians' knowledge, skills, confidence and attitudes will occur prior to and immediately after the intervention at each site, and again 6 months later. Questionnaires at 3 months following the intervention, and semi-structured interviews at 6 months with maternity service leaders will explore leaders' perceptions of acceptability, adoption, appropriateness, feasibility, adaptations and fidelity of delivery of the MOHMQuit intervention. Structural equation modelling will examine causal linkages between the strategies, mediators and outcomes. Cost-effectiveness analyses will also be undertaken.

DISCUSSION

This study will provide evidence of the effectiveness of a multi-level implementation intervention to support policy decisions; and evidence regarding mechanisms of action of the intervention strategies (how the strategies effected outcomes) to support further theoretical developments in implementation science.

TRIAL REGISTRATION

ACTRN12622000167763, registered February 2nd 2022.

Pregnant and postnatal women's experiences of interacting with health care providers about their tobacco smoking: a qualitative systematic review

OBJECTIVE

The objective of this review was twofold: (i) to comprehensively identify the best available evidence about the experiences of women who smoked tobacco during pregnancy or postnatally (or both) concerning health care providers' interactions with them about their smoking, when such interactions occurred during contact for prenatal or postnatal health care in any health care setting; and (ii) to synthesize the research findings for recommendations to strengthen health care providers' interventions regarding smoking during pregnancy and smoking during the postnatal period.

INTRODUCTION

Maternal tobacco smoking during pregnancy and maternal tobacco smoking postnatally pose serious health risks for the woman, fetus, and offspring, whereas maternal smoking cessation has beneficial health effects. Given the importance of health care providers' interactions with pregnant and postnatal women for smoking cessation care, it is essential to understand women's experiences of such interactions.

INCLUSION CRITERIA

Studies considered for this review had qualitative research findings about the experiences of women who smoked tobacco during pregnancy or postnatally (or both) in relation to health care providers' interactions with them about their smoking.

METHODS

The review was conducted using the JBI approach to qualitative systematic reviews. Published studies were sought through 6 academic databases (eg, CINAHL, MEDLINE). Unpublished studies were searched in 6 gray literature sources (eg, ProQuest Dissertations and Theses, Google Scholar). Reference lists of retrieved records were also searched. The searches occurred in October and November 2020; no country, language, or date limits were applied. Study selection involved title and abstract screening, full-text examination, and critical appraisal of all studies that met the inclusion criteria for the review. Study characteristics and research findings were extracted from the included studies. Study selection and extraction of findings were conducted by two reviewers independently; differences between reviewers were resolved through consensus. The research findings were categorized, and the categories were aggregated into a set of synthesized findings. The synthesized finding were assigned confidence scores. The categories and finalized synthesized findings were agreed upon by all reviewers.

RESULTS

The 57 included studies varied in qualitative research designs and in methodological quality (from mostly low to high). There were approximately 1092 eligible participants, and 250 credible and unequivocal research findings. The research findings yielded 14 categories and 6 synthesized findings with low to very low confidence scores. Some women who smoked tobacco during pregnancy and some women who smoked tobacco postnatally lacked supportive interactions by health care providers regarding their smoking; other women experienced supportive interactions by health care providers. Women were adversely impacted when health care providers' interactions lacked supportiveness, and were beneficially impacted when interactions were supportive. Women varied in openness to health care providers' interactions regarding their smoking, from not being receptive to being accepting, and some women wanted meaningful health care provider interactions.

CONCLUSIONS

Although confidence in the synthesized findings is low to very low, the evidence indicates that supportive health care provider interactions may facilitate positive smoking behavior change in pregnancy and postnatally. It is recommended that health care providers implement accepted clinical practice guidelines with women who smoke prenatally or postnatally, using an approach that is person-centered, emotionally supportive, engaging (eg, understanding), and non-authoritarian.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020178866.

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.

SISTAQUIT: training health care providers to help pregnant Aboriginal and Torres Strait Islander women quit smoking. A cluster randomised controlled trial

BACKGROUND

About 44% of Indigenous Australian women smoke during pregnancy, compared with 12% of pregnant non-Indigenous women. Health care providers can assist smoking cessation, but they are not typically trained in culturally appropriate methods.

OBJECTIVES

To determine whether a health care worker training intervention increases smoking cessation rates among Indigenous pregnant smokers compared with usual care.

METHODS AND ANALYSIS

Supporting Indigenous Smokers to Assist Quitting (SISTAQUIT) study is a multicentre, hybrid type 1, pragmatic, cluster randomised controlled trial that compares the effects of an intervention for improving smoking cessation by pregnant Indigenous women (16 years or older, 32 weeks' gestation or less) with usual care. Twenty-one health services caring for Indigenous people in five Australian jurisdictions were randomised to the intervention (ten sites) or control groups (eleven sites). Health care providers at intervention sites received smoking cessation care training based on the ABCD (ask/assess; brief advice; cessation; discuss psychosocial context) approach to smoking cessation for Indigenous women, an educational resource package, free oral nicotine replacement therapy for participating women, implementation support, and trial implementation training. Health care providers in control group services provided usual care.

PRIMARY OUTCOME

abstinence from smoking (self-reported abstinence via survey, validated by carbon monoxide breath testing when possible) four weeks after enrolment in the study.

SECONDARY OUTCOMES

health service process evaluations; knowledge, attitudes, and practices of health care providers; and longer term abstinence, perinatal outcomes, and respiratory outcomes for babies (to six months). Ethics approval: The human research ethics committees of the University of Newcastle (H-2015-0438) and the Aboriginal Health and Medical Research Council of NSW (1140/15) provided the primary ethics approval. Dissemination of results: Findings will be disseminated in peer-reviewed publications, at local and overseas conferences, and via public and social media, and to participating health services in art-based formats and reports. Policy briefs will be communicated to relevant government organisations.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry, ACTRN12618000972224 (prospective).

Risk of Gestational Diabetes Due to Maternal and Partner Smoking

Pregnant women are among the most vulnerable to environmental exposure to tobacco smoke (EET); which has been linked to problems in the mothers’ health; one of the most frequent is gestational diabetes (GD). For this reason, there are specific interventions and prevention strategies designed to reduce this exposure risk. However, currently, they are mostly aimed only at aiding the pregnant women with smoking cessation during pregnancy and do not assess or address the risk from passive exposure due to partner smoking. The aim of this work is to study the exposure to EET of pregnant women considering active and passive smoking and to evaluate its effect on the development of GD. This is an observational case-control study within a retrospective cohort of pregnant women. Information on smoking habits was obtained from both personal interviews and recorded medical history. In total, 16.2% of mothers and 28.3% of partners declared having been active smokers during pregnancy; 36.5% of the women presented EET during pregnancy when both active and passive smoking were considered. After adjustments, the association with the EET and GD of the mother was (aOR 1.10 95% CI: 0.64–1.92); for the EET of the partner, it was (aOR 1.66 95% CI: 1.01–2.77); for both partners, it was (aOR 1.82 95% CI: 1.15–2.89), adjusted by the mother’s age and body mass index. There is a lack of education regarding the effects of passive exposure to tobacco smoke. It is essential that pregnant women and their partners are educated on the risks of active and passive smoking; this could improve the effectiveness of other GD prevention strategies.

Optimizing Smoking Cessation Counseling in a University Hospital: Results and Pitfalls

Background

Healthcare professionals (HPs) can play a substantial role in smoking cessation counseling (SCC) but in practice often skip this task due to time constraints. This study evaluates the implementation of the rapid Ask-Advise-Connect (AAC) method in a University hospital setting.

Methods

This mixed methods pre-post interventional study was performed at the Cardiology department of a University hospital and consisted of (1) a quantitative assessment of patient smoking registration and HP connection rates to external SCC from the Electronic Medical Record, (2) semi-structured interviews with 10 HPs to assess their attitudes toward AAC, and (3) a blended intervention aimed to implement AAC. The blended intervention consisted of face-to-face and online AAC psychoeducation for HPs followed-up with motivational messages on their smart pagers over a period of 6 weeks.

Results

In total, 48,321 patient registrations and 67 HPs were included. Before AAC implementation, HPs assessed smoking status in 74.0% of patients and connected 9.3% of identified smokers with SCC. Post intervention, these percentages did not increase (73.2%, p = 0.20; and 10.9%, p = 0.18, respectively). Nonetheless, the vast majority (90%) of HPs feel it is important to discuss patient smoking, and view it as their duty to do so. Main barriers to AAC reported by HPs were forgetfulness and time pressure.

Conclusion

This study shows that this AAC intervention does not increase Asking after smoking status or Connection of patients to SCC in a University Hospital. However, HPs hold positive attitudes toward AAC. A better understanding of the mechanisms required for optimizing HPs practice behavior is needed.

"We're All Time Poor": Experienced Clinicians' and Students' Perceptions of Challenges Related to Patient Communication

PHENOMENON

Communication is a complex and essential element of clinical practice. It is widely accepted that communication skills can be taught and learned, but challenges remain for clinicians in achieving effective communication with patients. This study explored the patient-communication challenges faced by both medical students and experienced clinicians.

APPROACH

Semi-structured interviews were conducted with twenty medical students and nineteen experienced clinicians from a range of medical disciplines. Interviews were recorded and transcribed, and transcriptions subjected to thematic analysis and coding to quantify the challenges discussed.

FINDINGS

There was remarkable consistency in the challenges described by both groups of participants, with eight predominant challenges identified: time constraints and chaotic environments, rapport building, patient characteristics, reluctance, omissions, assumptions, decision-making, and keeping conversations focused.

INSIGHTS

Medical curricula often focus on communication challenges associated with complex or sensitive clinical situations, but many of the challenges identified occur in routine consultations. Both pre-service and post-graduate medical training should adopt strategies to help build students' and clinicians' skills in managing these challenges from the outset of training.

Improving implementation of smoking cessation guidelines in pregnancy care: development of an intervention to address system, maternity service leader and clinician factors

Background

Smoking during pregnancy increases the risk of multiple serious adverse infant, child and maternal outcomes, yet nearly 10% of Australian women still smoke during pregnancy. Despite evidence-based guidelines that recommend routine and repeated smoking cessation support (SCS) for all pregnant women, the provision of recommended SCS remains poor. Guidance on developing complex interventions to improve health care recommends drawing on existing theories, reviewing evidence, undertaking primary data collection, attending to future real-world implementation and designing and refining interventions using iterative cycles with stakeholder input throughout. Here, we describe using the Behaviour Change Wheel (BCW) and the Theoretical Domains Framework to apply these principles in developing an intervention to improve the provision of SCS in Australian maternity services.

Methods

Working closely with key stakeholders in the New South Wales (NSW) health system, we applied the steps of the BCW method then undertook a small feasibility study in one service to further refine the intervention. Stakeholders were engaged in multiple ways—as a core research team member, through a project Advisory Group, targeted meetings with policymakers, a large workshop to review potential components and the feasibility study.

Results

Barriers to and enablers of providing SCS were identified in five of six components described in the BCW method (psychological capability, physical opportunity, social opportunity and reflective and automatic motivation). These were mapped to intervention types and we selected education, training, enablement, environmental restructuring, persuasion, incentivisation and modelling as suitable in our context. Through application of the APEASE criteria (Affordability, Practicability, Effectiveness, Acceptability, Side effects and Equity) in the stakeholder workshop, behaviour change techniques were selected and applied in developing the intervention which includes systems, clinician and leadership elements. The feasibility study confirmed the feasibility and acceptability of the midwifery component and the need to further strengthen the leadership component.

Conclusions

Using the BCW method combined with strong stakeholder engagement from inception resulted in transparent development of the MOHMQuit intervention, which targets identified barriers to and enablers of the provision of SCS and is developed specifically for the context in which it will be implemented. The intervention is being trialled in eight public maternity services in NSW.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00235-5.

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.

Student nurses and midwives' experiences of teaching and learning about 'making every contact count' health behaviour change programme: Descriptive qualitative study

AIM/OBJECTIVE

To explore nursing/midwifery students' experiences of the teaching and learning of units one and two of a national undergraduate curriculum.

BACKGROUND

The 'National Undergraduate Curriculum for Chronic Disease Prevention and Management: Making Every Contact Count' (MECC) is part of Ireland's national policy to support the prevention of chronic disease by promoting health behaviour change. This is being implemented as a programme within the Irish Health Service and is also being delivered, for the first time in undergraduate medical, allied health and nursing/midwifery education by tertiary education institutes.

DESIGN

Qualitative descriptive research.

METHODS

Purposeful sampling was used to recruit participants (n = 17) from an undergraduate nursing/midwifery programme (n = 131) in one tertiary level Irish institution. Four focus groups were undertaken by two members of the research team, who were not part of the module teaching team. Each focus group was guided by a semi-structured interview guide, recorded and transcribed verbatim. Thematic data analysis was undertaken.

RESULTS

Three main themes were identified, namely: Building foundations and making connections; Personal responsibility and the Ah factor: now I understand.

CONCLUSION

Findings indicate that students had a positive learning experience whilst also highlighting the students' transition to lifelong learning encompassing adult learning and personal responsibility.

Improving Clinicians' Implementation of Guidelines to Help Women Stop Smoking in Pregnancy: Developing Evidence-Based Print and Video Materials

Smoking in pregnancy remains a public health challenge. Our team developed a comprehensive intervention using the Behaviour Change Wheel to support clinicians' implementation of guidelines on supporting women to stop smoking in pregnancy. Integral to the intervention was a suite of evidence-based video and print materials. This paper describes the rationale and process for developing these materials. Comprehensive mixed methods research was undertaken to identify the key barriers and enablers for clinicians in implementing the guidelines. This research identified which behaviours required change, and which behaviour change techniques were best suited to effecting that change. Materials were developed based on this understanding, in a collaborative process with multiple stakeholders, and their feasibility and acceptability explored in a small trial. Materials developed included leadership, clinician and client resources. There are considerable advantages to systematically and collaboratively developing materials which are integral to a behaviour-change intervention even though it is resource intensive to do so.

When primary care providers and smokers meet: a systematic review and metasynthesis

Primary Care Providers (PCPs) often deal with patients on daily clinical practice without knowing anything about their smoking status and willingness to quit. The aim of this metasynthesis is to explore the PCPs and patients who are smokers perspectives regarding the issue of smoking cessation within primary care settings. It relies on the model of meta-ethnography and follows thematic synthesis procedures. Twenty-two studies are included, reporting on the view of 580 participants. Three main themes emerge: (i) What lacks, (ii) Some expectations but no request, and (iii) How to address the issue and induce patients' motivation. Our results reveal a global feeling of a lack of legitimacy among PCPs when it comes to addressing the issue of tobacco and smoking cessation with their patients, even though they have developed creative strategies based on what is at the core of their practice, that is proximity, continuity, long-term and trustworthy relationship.

Feasibility of Audio-Recording Consultations with Pregnant Australian Indigenous Women to Assess Use of Smoking Cessation Behaviour Change Techniques

INTRODUCTION

Behavioural counselling is an effective method to improve smoking cessation during pregnancy. Audio recordings of consultations have been used previously to assess fidelity in specialized smoking cessation services, but not in primary care.

AIMS

The study is aimed at assessing the feasibility of audio-recording smoking cessation counselling as part of an intervention in primary care settings and exploring the number and type of behaviour change techniques (BCTs) delivered.

METHODS

This study was a nested feasibility study within a larger trial. Health providers (HPs) and pregnant women were asked to agree or decline audio recording their smoking-related consultations. Data collected included percentage providing consent, number of recordings performed, HP type, and date (pre/post intervention). Interviews were conducted to assess the trial procedures' acceptability.

RESULTS

Two services provided seven recordings, all pre-intervention. Of the 22 recruited women, 14 consented to being audio recorded (64%) and five provided recordings; of the 23 recruited HPs, 16 agreed (69%), and two provided recordings. Qualitative data suggest that HPs found audio recording difficult to remember. HPs spent on average two minutes discussing smoking and used few BCTs.

CONCLUSIONS

Audio recordings of smoking-related counselling were not feasible as planned. Future research will need to explore acceptable methods to assess BCT use in primary care.

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.

Supports Used by Aboriginal and Torres Strait Islander Women for Their Health, including Smoking Cessation, and a Baby's Health: A Cross-Sectional Survey in New South Wales, Australia

This study explored Aboriginal and Torres Strait Islander women’s use of supports for their general health, for smoking cessation, and the health of babies or children, and analyzed the women’s predictors for seeking types of support. Aboriginal and Torres Strait Islander women were recruited for a cross-sectional survey in two regions of NSW N = 132. The 19-item survey questioned the likelihood that the participant would use the various supports for their health, to quit smoking, and for a baby or child’s health. Logistic regression analyses were performed on N = 98 with complete data. Older participants were less likely to use Facebook or the internet for their health, or the health of a child, but were more likely to consult with health professionals. Women who had quit smoking were less likely to use an app for their health compared to smokers. Women who had a child living in their household were less likely to use the internet for a child’s health. This community-based study revealed age-related differences for access to health services and differences according to smoking status. Patterns of internet and app use warrant further consideration when planning strategies to improve Aboriginal and Torres Strait Islander women and children’s health.

General practitioner and obstetrician views on system changes to improve smoking cessation care in pregnancy in Australia: a cross-sectional survey

Introduction

Systemic barriers impacting smoking cessation in pregnant women may include nicotine replacement therapy (NRT) access and training.

Aim

Assess general practitioner (GP) and obstetrician's agreement with system-based changes to improve the management of smoking in pregnancy; compare group responses.

Methods

National cross-sectional survey with two samples: (1) online survey emailed to a random sample of 500 GPs from Royal Australian College of General Practitioners (RACGP); (2) paper survey posted to 5571 GPs and obstetricians from Royal Australia and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). Percentages agreeing that specified changes would improve the management of smoking in pregnancy were calculated. Pairwise comparisons used Kruskal–Wallis tests (RACGP/RANZCOG GPs/obstetricians).

Results

N = 378 participated. Response rates 8.4% (N = 42; online survey) and 6% (N = 335; paper survey), respectively. Total percentages agreeing with system-based changes: 79% training, 64% oral NRT subsidy, 62% Medicare item for smoking cessation, 54% improved access to NRT patches. Within RANZCOG, more GPs (73.1%) agreed that oral NRT should be subsidised (P = 0.001) than obstetricians (53.7%).

Conclusion

GPs and obstetricians agreed that system changes would improve their management of smoking in pregnancy. Oral NRT subsidy was the only pairwise group difference. Subsequently, oral NRT has been subsidised; in time, this may influence prescribing and quit rates.

Factors associated with provision of smoking cessation support to pregnant women - a cross-sectional survey of midwives in New South Wales, Australia

BACKGROUND

Smoking is the most important preventable cause of adverse pregnancy outcomes, but provision of smoking cessation support (SCS) to pregnant women is poor. We examined the association between midwives' implementation of SCS (5As - Ask, Advise, Assess, Assist, Arrange follow-up) and reported barriers/enablers to implementation.

METHODS

On-line anonymous survey of midwives providing antenatal care in New South Wales (NSW), Australia, assessing provision of the 5As and barriers/enablers to their implementation, using the Theoretical Domains Framework (TDF). Factor analyses identified constructs underlying the 5As; and barriers/enablers. Multivariate general linear models examined relationships between the barrier/enabler factors and the 5As factors.

RESULTS

Of 750 midwives invited, 150 (20%) participated. Respondents more commonly reported Asking and Assessing than Advising, Assisting, or Arranging follow-up (e.g. 77% always Ask smoking status; 17% always Arrange follow-up). Three 5As factors were identified- 'Helping', 'Assessing quitting' and 'Assessing dependence'. Responses to barrier/enabler items showed greater knowledge, skills, intentions, and confidence with Assessment than Assisting; endorsement for SCS as a priority and part of midwives' professional role; and gaps in training and organisational support for SCS. Nine barrier/enabler factors were identified. Of these, the factors of 'Capability' (knowledge, skills, confidence); 'Work Environment' (service has resources, capacity, champions and values SCS) and 'Personal priority' (part of role and a priority) predicted 'Helping'.

CONCLUSION

The TDF enabled systematic identification of barriers to providing SCS, and the multivariate models identified key contributors to poor implementation. Combined with qualitative data, these results have been mapped to intervention components to develop a comprehensive intervention to improve SCS.

Exposure to Tobacco, Environmental Tobacco Smoke and Nicotine in Pregnancy: A Pragmatic Overview of Reviews of Maternal and Child Outcomes, Effectiveness of Interventions and Barriers and Facilitators to Quitting

The aim of this review of reviews was to collate the latest evidence from systematic reviews about the maternal and child health outcomes of being exposed to tobacco and nicotine during pregnancy; the effectiveness of interventions designed to reduce these exposures, and barriers to and facilitators of smoking cessation during pregnancy. Two databases were searched to obtain systematic reviews published from 2010 to 2019. Pertinent data from 76 articles were summarized using a narrative synthesis (PROSPERO reference: CRD42018085896). Exposure to smoke or tobacco in other forms during pregnancy is associated with an increased risk of obstetric complications and adverse health outcomes for children exposed in-utero. Counselling interventions are modestly effective, while incentive-based interventions appear to substantially increase smoking cessation. Nicotine replacement therapy is effective during pregnancy but the evidence is not conclusive. Predictors and barriers to smoking cessation in pregnancy are also discussed. Smoking during pregnancy poses substantial risk to mother's and child's health. Psychosocial interventions and nicotine replacement therapy (NRT) appear to be effective in helping pregnant women quit smoking. Barriers to smoking cessation must be identified and steps taken to eradicate them in order to reduce smoking among pregnant women. More research is needed on smoking cessation medications and e-cigarettes.

Barriers and enablers to implementation of antenatal smoking cessation guidelines in general practice

Smoking is a major preventable cause of adverse outcomes in pregnancy. Despite the existence of smoking cessation support guidelines, many pregnant smokers do not receive support in quitting. The aim of this study was to identify and understand the facilitators and barriers experienced by GPs in implementing the 5As of smoking cessation support with pregnant women. The results of this study may help in shaping interventions to support GPs in implementing the guidelines. This was a qualitative study using semi-structured interviews built around the Theoretical Domains Framework. Participants were 15 GPs, and thematic analysis was used to identify relevant themes. Perceived barriers to implementing guidelines included unfamiliarity with the 5As, uncertainty using nicotine replacement therapy, lack of time, and fears of damaging rapport. Perceived facilitators included high levels of knowledge and skills, patients' expectations and a recognition that smoking cessation was a fundamental and essential part of the GPs' role in antenatal care. Educating and training GPs regarding the 5As and NRT (nicotine replacement therapy) use in pregnancy may have a role in improving delivery of smoking cessation support. The strong overall commitment to provision of smoking cessation support among GPs may also have a role in developing interventions in the future.

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.

What components of smoking cessation care during pregnancy are implemented by health providers? A systematic review and meta-analysis

BACKGROUND

Pregnancy is an opportunity for health providers to support women to stop smoking.

OBJECTIVES

Identify the pooled prevalence for health providers in providing components of smoking cessation care to women who smoke during pregnancy.

DESIGN

A systematic review synthesising original articles that reported on (1) prevalence of health providers' performing the 5As ('Ask', 'Advise', 'Assess', 'Assist', 'Arrange'), prescribing nicotine replacement therapy (NRT) and (2) factors associated with smoking cessation care.

DATA SOURCES

MEDLINE, EMBASE, CINAHL and PsycINFO databases searched using 'smoking', 'pregnancy' and 'health provider practices'.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies included any design except interventions (self-report, audit, observed consultations and women's reports), in English, with no date restriction, up to June 2017.

PARTICIPANTS

Health providers of any profession.

DATA EXTRACTION, APPRAISAL AND ANALYSIS

Data were extracted, then appraised with the Hawker tool. Meta-analyses pooled percentages for performing each of the 5As and prescribing NRT, using, for example, 'often/always' and 'always/all'. Meta-regressions were performed of 5As for 'often/always'.

RESULTS

Of 3933 papers, 54 were included (n=29 225 participants): 33 for meta-analysis. Health providers included general practitioners, obstetricians, midwives and others from 10 countries. Pooled percentages of studies reporting practices 'often/always' were: 'Ask' (n=9) 91.6% (95% CI 88.2% to 95%); 'Advise' (n=7) 90% (95% CI 72.5% to 99.3%), 'Assess' (n=3) 79.2% (95% CI 76.5% to 81.8%), 'Assist (cessation support)' (n=5) 59.1% (95% CI 56% to 62.2%), 'Arrange (referral)' (n=6) 33.3% (95% CI 20.4% to 46.2%) and 'prescribing NRT' (n=6) 25.4% (95% CI 12.8% to 38%). Heterogeneity (I2) was 95.9%-99.1%. Meta-regressions for 'Arrange' were significant for year (p=0.013) and country (p=0.037).

CONCLUSIONS

Health providers 'Ask', 'Advise' and 'Assess' most pregnant women about smoking. 'Assist', 'Arrange' and 'prescribing NRT' are reported at lower rates: strategies to improve these should be considered.

PROSPERO REGISTRATION NUMBER

CRD42015029989.

Golden Age of Medicine 2.0: Lifestyle Medicine and Planetary Health Prioritized

The 'golden age of medicine' - the first half of the 20th century, reaching its zenith with Jonas Salk's 1955 polio vaccine - was a time of profound advances in surgical techniques, immunization, drug discovery, and the control of infectious disease; however, when the burden of disease shifted to lifestyle-driven, chronic, non-communicable diseases, the golden era slipped away. Although modifiable lifestyle practices now account for some 80% of premature mortality, medicine remains loathe to embrace lifestyle interventions as medicine Here, we argue that a 21st century golden age of medicine can be realized; the path to this era requires a transformation of medical school recruitment and training in ways that prioritize a broad view of lifestyle medicine. Moving beyond the basic principles of modifiable lifestyle practices as therapeutic interventions, each person/community should be viewed as a biological manifestation of accumulated experiences (and choices) made within the dynamic social, political, economic and cultural ecosystems that comprise their total life history. This requires an understanding that powerful forces operate within these ecosystems; marketing and neoliberal forces push an exclusive 'personal responsibility' view of health - blaming the individual, and deflecting from the large-scale influences that maintain health inequalities and threaten planetary health. The latter term denotes the interconnections between the sustainable vitality of person and place at all scales. We emphasize that barriers to planetary health and the clinical application of lifestyle medicine - including authoritarianism and social dominance orientation - are maintaining an unhealthy status quo.

Surgeons and preventive health: a mixed methods study of current practice, beliefs and attitudes influencing health promotion activities amongst public hospital surgeons

Background

Little is known about the participation of surgeons in preventative health activities in the non-admitted hospital care setting. The aim of this study was to identify which preventive health activities surgeons practice and to explore their attitudes towards preventive health.

Methods

A mixed methods study was conducted using a sequential explanatory design. Quantitative results were obtained from a self-reported clinician survey (n = 16) and a Generalized Estimating Equation was used to assess the relationship between dependent (preventive health practice) and independent (confidence and knowledge in preventive health practice, years of practice, and attitudinal factors) variables. Using a building approach to integration, results from the quantitative analyses informed design of the interview guide. Surgeons’ beliefs and attitudes were explored using in-depth, semi structured interviews with a purposeful sample of surgeons (n = 14). Responses were collected, independently coded and analysed using a qualitative descriptive approach.

Results

In accordance with a contiguous narrative approach to integration, the quantitative and qualitative findings are reported separately. The clinician survey found that the surgeons carried out preventive health activities at low levels. Preventive health advice was predominantly verbal in nature, and few surgeons provided written material or referred patients to additional services. The GEE analyses indicated that the following factors best predicted the tendency to undertake preventive health activities: years of clinical practice (p = 0.041), and the perceived work priority placed on preventive health (p = 0.008). Interviews generated four themes that influenced the tendency of surgeons to undertake preventive health activities: perceptions of their role in preventive health, perceived motivation of patients, hospital structure, and facilitating factors. In regards to enabling factors that are likely to increase preventive health practice, surgeons unanimously advocated for referral pathways into specialist behaviour change programs that they could facilitate within their relatively brief consulting time.

Conclusions

The findings suggests that the majority of public hospital surgeons engage in routine preventive health advice at a low level. The high volume of non-admitted surgical consultations undertaken annually, coupled with medium to high self-reported knowledge and confidence in addressing behavioural risk factors, support an increased involvement of surgeons in preventive health practice.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4186-y) contains supplementary material, which is available to authorized users.

Improving smoking cessation care in pregnancy at Aboriginal Medical Services: 'ICAN QUIT in Pregnancy' step-wedge cluster randomised study

OBJECTIVES

This study aimed to examine the impact of the 'ICAN QUIT in Pregnancy' intervention on individual health providers (HPs) smoking cessation care (SCC) knowledge, attitudes and practices in general, and specifically regarding nicotine replacement therapy (NRT) prescription.

DESIGN

Step-wedge clustered randomised controlled study. HPs answered a preintervention and 1-6 months postintervention survey.

SETTING

Six Aboriginal Medical Services (AMSs) in three states of Australia.

PARTICIPANTS

All HPs were invited to participate. Of 93 eligible, 50 consented (54%), 45 completed the presurvey (90%) and 20 the post (40%).

INTERVENTION

Included three 1-hour webinar sessions, educational resource package and free oral NRT.

OUTCOMES

HPs knowledge was measured using two composite scores-one from all 24 true/false statements, and one from 12 NRT-specific statements. Self-assessment of 22 attitudes to providing SCC were measured using a five-point Likert scale (Strongly disagree to Strongly agree). Two composite mean scores were calculated-one for 15 general SCC attitudes, and one for 7 NRT-specific attitudes. Self-reported provision of SCC components was measured on a five-point Likert scale (Never to Always). Feasibility outcomes, and data collected on the service and patient level are reported elsewhere.

RESULTS

Mean knowledge composite scores improved from pre to post (78% vs 84% correct, difference 5.95, 95% CI 1.57 to 10.32). Mean NRT-specific knowledge composite score also improved (68% vs 79% correct, difference 9.9, 95% CI 3.66 to 16.14). Mean attitude composite score improved (3.65 (SD 0.4) to 3.87 (SD 0.4), difference 0.23, 95% CI 0.05 to 0.41). Mean NRT-specific attitudes composite score also improved (3.37 (SD 0.6) to 3.64 (SD 0.7), difference 0.36, 95% CI 0.13 to 0.6). Self-reported practices were unchanged, including prescribing NRT.

CONCLUSIONS

A multicomponent culturally sensitive intervention in AMSs was feasible, and might improve HPs provision of SCC to pregnant Aboriginal women. Changes in NRT prescription rates may require additional intensive measures.

TRIAL REGISTRATION NUMBER

ACTRN 12616001603404; Results.

The association between the receipt of primary care clinician provision of preventive care and short term health behaviour change

Primary healthcare services are recommended to provide preventive care to address chronic disease risk behaviours. However, all care elements are infrequently provided, and there is a need to understand the impact of partial care provision on behaviour change. This study examined the association between variable levels of preventive care receipt from primary care clinicians on short-term behaviour change for four risk behaviours. A survey was undertaken with 5639 Australian community health service clients (2009-2014). Clients self-reported: engagement in risk behaviours (tobacco smoking, harmful alcohol consumption, inadequate fruit and/or vegetable consumption, physical inactivity) in the month prior to and four week post their community health service appointment; receipt of preventive care during appointments (assessment, advice, referral/follow-up) for each behaviour. Univariate regression models explored the association between change in risk status and preventive care received. The odds of behaviour change for those receiving all three care elements was significant for all behaviours, compared to no care, ranging from 2.02 (alcohol consumption, 95% CI 1.16-3.49) to 4.17 (inadequate fruit and/or vegetable consumption, 95% CI 2.91-5.96). Receipt of both assessment and advice increased the odds of behaviour change, compared to no care, for all behaviours except smoking, ranging from 2.32 (physical inactivity, 95% CI 1.60-3.35) to 2.83 (alcohol consumption, 95% CI 1.84-4.33). Receipt of 'assessment only' increased the odds of behaviour change, compared to no care, for inadequate fruit and/or vegetable consumption (OR = 2.40, 95% CI 1.60-3.59) and physical inactivity (OR = 2.81, 95% CI 1.89-4.17). Results highlight the importance of primary care clinicians providing best practice preventive care to maximise client behaviour change.

Feasibility and acceptability of Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy multicomponent implementation intervention and study design for Australian Indigenous pregnant women: A pilot cluster randomised step-wedge trial

BACKGROUND

Many health providers (HPs) lack knowledge, confidence, optimism and skills in addressing smoking with pregnant women. This study aimed to explore the feasibility and acceptability of a) a co-designed multi-component intervention for HPs at Aboriginal Medical Services (AMSs) in culturally-targeted pregnancy-specific smoking cessation care and b) the study design.

METHODS

Using a randomised step-wedge cluster design, the Indigenous Counselling And Nicotine (ICAN) QUIT in Pregnancy Trial was evaluated across six AMSs in three Australian states. HPs were provided educational resource packages including live interactive webinars, treatment manuals, patient resources, carbon monoxide (CO) meters, and oral Nicotine Replacement Therapy (NRT). Feasibility was assessed through recruitment and retention rates of both pregnant women (12-weeks) and HPs (end of study) as well as the potential to improve women's quit rates. Qualitative interviews with staff post-trial explored acceptability of the intervention and study, based on capability, opportunity and motivation from the Behaviour Change Wheel.

RESULTS

Pregnant women (n = 22; 47% (95% CI: 32%, 63%) eligible) and HPs (n = 50; 54% (95% CI: 44%, 64%) eligible) were recruited over 6 months with retention rates of 77% (95% CI: 57%, 90%) and 40% (95% CI: 28%, 54%) respectively. Self-reported 12-week 7-day point-prevalence abstinence was 13.6% (n = 3) and validated abstinent with CO readings ≤6 ppm. Staff interviewed regarding intervention implementation highlighted the importance of provision and use of resources, including training materials, patient resources, CO meters and oral NRT. Resources helped increase capability and opportunity, restructure the environment, and provided social comparison and modelling. Staff were motivated by greater engagement with pregnant women and seeing the women's reductions in CO readings. Having the intervention at the AMSs improved organisational capacity to engage with pregnant women. Staff reported changes to their routine practice that were potentially sustainable. Recommendations for improvement to the implementation of the intervention and research included reducing training length and the tasks related to conducting the study.

CONCLUSION

ICAN QUIT in Pregnancy was a pilot study with the ability to enrol Indigenous women. It was feasible to implement and acceptable to most staff of the AMSs in three states, with modifications recommended. Smoking in pregnancy is a key challenge for Indigenous health. The intervention needs to be evaluated through a methodologically rigorous fully-powered study to determine the efficacy of outcomes for women.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry, ACTRN12616001603404. Registered 21 November 2016 - retrospectively registered, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371778.

Overcoming Challenges to Treating Tobacco use During Pregnancy - A Qualitative study of Australian General Practitioners Barriers

Background

General practitioners can play an important role in addressing smoking among pregnant women but studies suggest they rarely do so. The aim of this study was to explore general practitioners perceptions about the management of smoking in pregnancy, and what would enable them to provide better care.

Methods

Qualitative semi-structured interviews were conducted (Feb-July 2017), with 19 Australian general practitioners recruited from a sample that participated in a national survey on managing smoking during pregnancy; and through a national conference. The interview guide was structured using the theoretical domains framework, exploring previously reported barriers and two specific components of smoking cessation care - nicotine replacement therapy prescription and Quitline referral.

Results

Participants reported high confidence and knowledge to provide pregnant patients adequate support for quitting. Nonetheless, participants reported lacking communication skills, focusing on providing information on smoking harm, accepting cutting down cigarettes as adequate, while following the ‘Stages of Change’ model and only providing treatment options to motivated patients. Lack of time, nicotine replacement therapy cost and safety concerns, and being unfamiliar with the Quitline (particularly for Aboriginal and Torres Strait Islander pregnant smokers) were perceived as challenges. Participants reported needing better communication skills, clear detailed nicotine replacement therapy guidelines for special populations, and visual resources they could use to discuss treatment options with patients.

Conclusions

Difficulty communicating with pregnant patients about smoking, using the ‘Stages of Change’ model to guide support provision and concerns regarding nicotine replacement therapy safety are barriers to providing cessation support to pregnant patients for general practitioners. Training on specific effective behaviour change techniques, clear guidance for nicotine replacement therapy use, and practical visual patient education tools may facilitate smoking cessation care provision to pregnant women.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2208-8) contains supplementary material, which is available to authorized users.

Nicotine replacement therapy for smoking cessation during pregnancy

Nicotine replacement therapy (NRT) is recommended in current Australian clinical guidelines for pregnant women who are unable to quit smoking unassisted. Clinicians report low levels of prescribing NRT during pregnancy, due to safety concerns and low levels of confidence in their ability to prescribe NRT. Animal models show that nicotine is harmful to the fetus, especially for brain and lung development, but human studies have not found any harmful effects on fetal and pregnancy outcomes. Studies of efficacy and effectiveness in the real world suggest that NRT use during pregnancy increases smoking cessation rates. These rates may be hampered by the fact that studies so far have used an NRT dose that does not adequately account for the higher nicotine metabolism during pregnancy and, therefore, does not adequately treat withdrawal symptoms. Further research is needed to assess the safety and efficacy of higher dosages of NRT in pregnancy, specifically of combination treatment using dual forms of NRT. As NRT is safer than smoking, clinicians need to offer this option to all pregnant women who smoke. A practical guide for initiating and tailoring the dose of NRT in pregnancy is suggested.

Quit-smoking counselling in Dutch midwifery practices: Barriers to the implementation of national guidelines

OBJECTIVE

Although smoking during pregnancy can have severe health consequences for the (unborn) child, 9% of Dutch pregnant women smoke at any time during their pregnancy. Midwives in the Netherlands are a responsible party in the provision of quit-smoking counselling for pregnant women by means of the 7-step `V-MIS' intervention, but in practice the implementation appears to be suboptimal. The purpose of the present study was to assess the provision of quit-smoking counselling by midwives, and to clarify the nature and extent of any existing barriers and needs in the provision of quit-smoking counselling in Dutch midwifery settings.

METHODS

An online questionnaire to the target population of Dutch midwives (N ≈ 3150) was set out in the spring of 2016. The questionnaire included items on the provision of quit-smoking counselling for pregnant women, and on possible barriers and needs regarding the provision of this counselling. Descriptive statistics were used to analyse weighed data from 135 midwives representative for the Dutch setting in terms of age, function, and region.

RESULTS

Eighty-one percent of the midwives inquire about smoking profile (V-MIS step 1) but only 10% go through all the V-MIS counselling steps (i.e. up to discussing postnatal passive smoking and smoke free breastfeeding, step 7). Although 74% of the midwives regard it as their task to provide quit-smoking guidance to pregnant women, 77% perceive referral to a professional as a useful strategy (mostly to the GP; 74%). For 61% of the midwives, their clients' lack of motivation undermines the provision of quit-smoking counselling. Other hindering factors are the perceived lack of free brochures (54%), simple tools or gadgets (51%), and financial consequences for the midwife (37%) and/or the client (22%).

CONCLUSION

The smoking cessation intervention strategy currently imposed in Dutch midwifery practices (V-MIS) is being used by midwives, however its implementation may considerably benefit from strengthening skills in motivational interviewing techniques, provision of supporting materials, and structural embedding of GP referral. Based on the study's findings, practical recommendations are made to facilitate the provision of quit-smoking counselling in (international) midwifery settings.

Are healthcare professionals delivering opportunistic behaviour change interventions? A multi-professional survey of engagement with public health policy

BACKGROUND

"Making Every Contact Count" (MECC), a public health policy in the UK, compels healthcare professionals to deliver opportunistic health behaviour change interventions to patients during routine medical consultations. Professionals' awareness of, and engagement with, the policy is unclear. This study examined (1) awareness of the MECC policy, and (2) the prevalence of MECC-related practice in relation to (a) perceived patient benefit, (b) how often healthcare professionals deliver interventions during routine consultations, and (c) the time spent on this activity.

METHODS

Cross-sectional national survey was administered in 2017 of 1387 healthcare professionals working in the UK's National Health Service (NHS). Descriptive statistics were used to assess awareness and practice consistent with the MECC policy. Chi-square was used to gauge the potential representativeness of our sample compared to NHS employment data.

RESULTS

31.4% of healthcare professionals reported having heard of the policy; nevertheless, healthcare professionals perceived a need to provide patients with opportunistic behaviour change interventions in 55.9% (32,946/58,906) of consultations. However, healthcare professionals did not deliver interventions on 50.0% of occasions in which they perceived a need. Where behaviour change interventions were delivered to patients, this constituted 35.3% of the appointment time.

CONCLUSIONS

Policy makers must address the gap between the proportion of patients that healthcare professionals perceive would benefit from opportunistic behaviour change interventions and those receiving them (an estimated 50.0%; 16,473 additional patients could have benefited). Future research should consider how healthcare professionals identify patients who might benefit from opportunistic behaviour change interventions and developing training for efficient delivery of interventions.

Addressing smoking among people living with HIV: a cross-sectional survey of Australian HIV health practitioners' practices and attitudes

People living with HIV (PLHIV) have high rates of tobacco smoking, and smoking is a leading cause of premature mortality and morbidity. It is important to understand HIV healthcare providers' practices and attitudes towards addressing smoking with their patients. An online survey that measured: (i) use of the 5A framework for addressing smoking (Ask, Assess, Advise, Assist, Arrange) and (ii) attitudes and barriers to addressing smoking cessation was distributed by relevant professional bodies. Eligible participants were Australian health practitioners providing healthcare to PLHIV. Of the 179 respondents, most reported practising at least one of the 5As: Ask (94%); Assess (78%); Advise (82%); Assist (89%); and Arrange (73%). Practising the full 5A framework (completing at least one activity from each A) was less common (62%) and associated with having undertaken smoking cessation training (OR 2.1, CI 1.1-3.9), being a medical practitioner (OR 6.0, CI 3.1-11.6), having greater perceived knowledge and resources (OR 1.7, CI 1.3-2.4) and more positive attitudes (OR 1.5, CI 1.1-2.0). Common barriers to delivering cessation assistance related to knowledge and availability of resources. Development and greater dissemination of effective smoking cessation training and resources may be required to ensure healthcare practitioners have the capacity to complete all aspects of the 5A framework for smoking cessation and support their patients with HIV who smoke.

Do Clinicians Ask Pregnant Women about Exposures to Tobacco and Cannabis Smoking, Second-Hand-Smoke and E-Cigarettes? An Australian National Cross-Sectional Survey

Clinicians often ask pregnant women about tobacco smoking, but their practices of asking about other smoking and nicotine exposures are unknown. This study analysed how often clinicians ask pregnant women about their use of e-cigarettes, cannabis, chewing tobacco, and second-hand smoke (SHS) exposure. Two cross-sectional surveys were undertaken. A random sample of 500 General Practitioner (GP) members were invited from the National Faculty of Aboriginal and Torres Strait Islander Health (NFATSIH) to complete an on-line survey, and 5571 GP and Obstetrician (OBS) members of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) were sent a paper survey by mail. Questions on frequency of asking about the exposures used Likert Scales, later dichotomized to "often-always" and "never-sometimes". Logistic regressions estimated associations between clinician type and asking about cannabis, e-cigarettes, chewing tobacco, and SHS. An adjusted model reduced potential confounders of location, guidelines, gender and population. n = 378 GPs and OBS participated (6.2% response). In total, 13-14% asked "often-always" about e-cigarettes; 58% cannabis; 38% cannabis with tobacco; 27% SHS, and 10% chewing tobacco-compared to 95% of the sample asking about cigarette smoking. After adjustment, the odds of RANZCOG GPs (OR 0.34) and OBS (OR 0.63) asking about cannabis were lower compared to NFATSIH GPs. Clinician type was non-significant for asking about e-cigarettes, chewing tobacco and SHS. Surveyed Australian GPs and obstetricians asked less frequently about e-cigarettes, chewing, SHS exposure, and cannabis, potentially missing important exposures for mother and child.

Clinician factors associated with prescribing nicotine replacement therapy in pregnancy: A cross-sectional survey of Australian obstetricians and general practitioners

The use of nicotine replacement therapy in pregnancy has been debated but evidence suggests that it is safer than smoking. A cross-sectional survey was conducted with: (i) general practitioners and obstetricians from a college database; and (ii) general practitioners with a special interest in Indigenous health. General practitioners had higher odds of prescribing compared to obstetricians. Reading guidelines, confidence, viewing nicotine replacement therapy as safe, effective and with good adherence, also significantly increased the odds of prescription. Clear guidance regarding safety and efficacy, with practical clinical protocols, are required in order to reduce variation in prescribing rates across these clinicians.

Smoking during pregnancy in the United States, 2005-2014: The role of depression

BACKGROUND

Despite success of public health-oriented tobacco control programs in lowering the smoking prevalence over the past several decades, it is unclear whether similar reductions in smoking have been experienced among pregnant women, especially in vulnerable groups such as those with major depression and/or lower socioeconomic status.

OBJECTIVES

The purpose of this study is to examine the relationship between major depressive episode (MDE) and smoking among pregnant women overall, and by demographics and to estimate changes in the prevalence of cigarette smoking among pregnant women with and without MDE from 2005 to 2014.

STUDY DESIGN

Cigarette use among pregnant women with and without MDE was examined using logistic regression models in the National Survey on Drug Use and Health.

RESULTS

Prenatal smoking is more common among pregnant women with, compared to without, MDE (32.5% vs. 13.0%; (adjusted OR=2.50 (1.85, 3.40)), and greater disparities were revealed when also considering income, education and race. Over time, smoking during pregnancy increased significantly among women with MDE (35.9% to 38.4%; p=0.02)) and showed a decreasing trend among women without MDE (12.5% to 9.1%; p=0.07) from 2005 to 2014.

CONCLUSIONS

Over the past decade, smoking during pregnancy has increased among women experiencing a major depressive episode and is over four times more common among pregnant women with, than without, MDE. Disparities in smoking during pregnancy by MDE status and socioeconomic subgroups appear substantial. Given the multitude of risks associated with both MDE and smoking during the prenatal period, more work targeting this vulnerable and high-risk group is needed.

Assessing and Validating an Educational Resource Package for Health Professionals to Improve Smoking Cessation Care in Aboriginal and Torres Strait Islander Pregnant Women

Australian Aboriginal pregnant women have a high smoking prevalence (45%). Health professionals lack adequate educational resources to manage smoking. Resources need to be tailored to ensure saliency, cultural-sensitivity and account for diversity of Indigenous populations. As part of an intervention to improve health professionals' smoking cessation care in Aboriginal pregnant women, a resource package was developed collaboratively with two Aboriginal Medical Services. The purpose of this study was to assess and validate this resource package. A multi-centred community-based participatory 4-step process (with three Aboriginal Medical Services from three Australian states), included: (1) Scientific review by an expert panel (2) 'Suitability of Materials' scoring by two Aboriginal Health Workers (3) Readability scores (4) Focus groups with health professionals. Content was analysed using six pre-determined themes (attraction, comprehension, self-efficacy, graphics and layout, cultural acceptability, and persuasion), with further inductive analysis for emerging themes. Suitability of Material scoring was adequate or superior. Average readability was grade 6.4 for patient resources (range 5.1-7.2), and 9.8 for health provider resources (range 8.5-10.6). Emergent themes included 'Getting the message right'; 'Engaging with family'; 'Needing visual aids'; and 'Requiring practicality under a tight timeframe'. Results were presented back to a Stakeholder and Consumer Aboriginal Advisory Panel and resources were adjusted accordingly. This process ensured materials used for the intervention were culturally responsive, evidence-based and useful. This novel formative evaluation protocol could be adapted for other Indigenous and culturally diverse interventions. The added value of this time-consuming and costly process is yet to be justified in research, and might impact the potential adaption by other projects.

Designing an implementation intervention with the Behaviour Change Wheel for health provider smoking cessation care for Australian Indigenous pregnant women

BACKGROUND

Indigenous smoking rates are up to 80% among pregnant women: prevalence among pregnant Australian Indigenous women was 45% in 2014, contributing significantly to the health gap for Indigenous Australians. We aimed to develop an implementation intervention to improve smoking cessation care (SCC) for pregnant Indigenous smokers, an outcome to be achieved by training health providers at Aboriginal Medical Services (AMS) in a culturally competent approach, developed collaboratively with AMS.

METHOD

The Behaviour Change Wheel (BCW), incorporating the COM-B model (capability, opportunity and motivation for behavioural interventions), provided a framework for the development of the Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy implementation intervention at provider and patient levels. We identified evidence-practice gaps through (i) systematic literature reviews, (ii) a national survey of clinicians and (iii) a qualitative study of smoking and quitting with Aboriginal mothers. We followed the three stages recommended in Michie et al.'s "Behaviour Change Wheel" guide.

RESULTS

Targets identified for health provider behaviour change included the following: capability (psychological capability, knowledge and skills) by training clinicians in pharmacotherapy to assist women to quit; motivation (optimism) by presenting evidence of effectiveness, and positive testimonials from patients and clinicians; and opportunity (environmental context and resources) by promoting a whole-of-service approach and structuring consultations using a flipchart and prompts. Education and training were selected as the main intervention functions. For health providers, the delivery mode was webinar, to accommodate time and location constraints, bringing the training to the services; for patients, face-to-face consultations were supported by a booklet embedded with videos to improve patients' capability, opportunity and motivation.

CONCLUSIONS

The ICAN QUIT in Pregnancy was an intervention to train health providers at Aboriginal Medical Services in how to implement culturally competent evidence-based practice including counselling and nicotine replacement therapy for pregnant patients who smoke. The BCW aided in scientifically and systematically informing this targeted implementation intervention based on the identified gaps in SCC by health providers. Multiple factors impact at systemic, provider, community and individual levels. This process was therefore important for defining the design and intervention components, prior to a conducting a pilot feasibility trial, then leading on to a full clinical trial.

The Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy Pilot Study protocol: a feasibility step-wedge cluster randomised trial to improve health providers' management of smoking during pregnancy

INTRODUCTION

Indigenous women have the highest smoking prevalence during pregnancy (47%) in Australia. Health professionals report lack of knowledge, skills and confidence to effectively manage smoking among pregnant women in general. We developed a behaviour change intervention aimed to improve health professionals' management of smoking in Indigenous pregnant women-the Indigenous Counselling And Nicotine (ICAN) QUIT in Pregnancy. This intervention includes webinar training for health professionals, an educational resources package for health professionals and pregnant women, free oral nicotine replacement therapy (NRT) for pregnant women, and audit and feedback on health professionals' performance.The aim of this study is to test the feasibility and acceptability of the ICAN QUIT in Pregnancy intervention to improve health professionals' provision of evidence-based culturally responsive smoking cessation care to Australian Indigenous pregnant smokers.

METHODS AND ANALYSIS

This protocol describes the design of a step-wedge cluster randomised pilot study. Six Aboriginal Medical Services (AMSs) are randomised into three clusters. Clusters receive the intervention staggered by 1 month. Health professionals report on their knowledge and skills pretraining and post-training and at the end of the study. Pregnant women are recruited and followed up for 3 months. The primary outcome is the recruitment rate of pregnant women. Secondary outcomes include feasibility of recruitment and follow-up of participating women, and webinar training of health professionals, measured using a designated log; and measures of effectiveness outcomes, including quit rates and NRT prescription rates.

ETHICS AND DISSEMINATION

In accordance with the Aboriginal Health and Medical Research Council guidelines, this study has been developed in collaboration with a Stakeholder and Consumer Aboriginal Advisory Panel (SCAAP). The SCAAP provides cultural consultation, advice and direction to ensure that implementation is acceptable and respectful to the Aboriginal communities involved. Results will be disseminated to AMSs, Aboriginal communities and national Aboriginal bodies.

REGISTRATION DETAILS

This protocol (version 4, 14 October 2016) is registered with the Australian and New Zealand Clinical Trials Registry (Ref #: ACTRN12616001603404).

Prevention and Treatment of Smoking and Tobacco Use During Pregnancy in Selected Indigenous Communities in High-Income Countries of the United States, Canada, Australia, and New Zealand: An Evidence-Based Review

Tobacco smoking during pregnancy is the most important modifiable risk factor for adverse pregnancy outcomes and long-term health complications for mother and baby. Tobacco use during pregnancy has decreased in high-income countries but not in Indigenous women in Australia, New Zealand, the United States, and Canada. This evidence-based review focuses on tobacco use among Indigenous pregnant women in high-income countries that share a history of European colonization. Indigenous women are more likely to use tobacco because of socioeconomic disadvantage, social norms, and poor access to culturally appropriate tobacco cessation support. Complications arising from tobacco smoking during pregnancy, such as low birth weight, prematurity, perinatal death, and sudden infant death syndrome, are much higher in Indigenous populations. Effective approaches to cessation in pregnant nonindigenous women involves behavioral counseling, with or without nicotine replacement therapy (NRT). Higher nicotine metabolism during pregnancy and poor adherence may affect therapeutic levels of NRT. Only two randomized trials were conducted among Indigenous women: neither found a statistically significant difference in cessation rates between the treatment and comparison arms. Considerations should be given to (1) whole life course approaches to reduce tobacco use in Indigenous women, (2) prohibiting tobacco promotion and reducing access to alcohol for minors to prevent smoking initiation in Indigenous youth, and (3) training health-care professionals in culturally appropriate smoking cessation care to improve access to services. It is critical to ensure acceptability and feasibility of study designs, consult with the relevant Indigenous communities, and preempt implementation challenges. Research is needed into the effect of reducing or stopping smoking during pregnancy when using NRT on subsequent maternal and infant outcomes.

Smoking in Pregnancy Among Indigenous Women in High-Income Countries: A Narrative Review

INTRODUCTION

Pregnant women in socioeconomically disadvantaged circumstances, such as Indigenous women, have a high prevalence of smoking. Tobacco smoking is the most significant reversible risk factor for the health of Indigenous pregnant women and their babies.

METHODS

As researchers working in this specialized area, we conducted a narrative review of the literature on smoking among Indigenous pregnant women in the United States, Canada, New Zealand, and Australia. We summarize prevalence and factors influencing tobacco use, interventions, and evidence gaps for tobacco control and smoking cessation. Recommendations are made for future interventions, policy changes, and much-needed research.

RESULTS

Common themes emerging across the four countries reveal opportunities for cross-cultural collaborative studies and trials. These include the social-normative use of tobacco as barriers to quitting in pregnancy and the need for evaluations of interventions at the family and community level. Socioeconomic disparities underscore the importance of enhancing the implementation and reach of strategies to prevent and reduce prenatal tobacco smoking among Indigenous women. Elders and community health care providers as role models for nontobacco use could be explored. Qualitative work is needed to understand the barriers and opportunities, such as cultural strengths supporting quitting tobacco to develop more effective approaches.

CONCLUSIONS

Although a high-priority group, there remains a dearth of research on Indigenous women's smoking in pregnancy. Studies have assessed knowledge and attitudes to smoking in pregnancy, and small feasibility studies and a few empirical trials have been conducted. Recommendations for promising culturally appropriate cessation interventions have been made. Larger trials are warranted.

IMPLICATIONS

Strategies to support quitting among pregnant Indigenous women need to be multifactorial and take account of the social determinants of smoking including historical antecedents, community norms, cultural strengths, and recognition of individual and community needs. Cross-country research collaborations have the potential to leverage funding, share expertise, and strengthen approaches to tackle an important and poorly attended health disparity that has a profound impact on the entire life course for Indigenous peoples.