Integrating Prenatal-Postnatal Smoking Interventions into Usual Care in a Health Maintenance Organization

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.

Improving health providers smoking cessation care in pregnancy: A systematic review and meta-analysis

INTRODUCTION

Health providers are lacking in their provision of smoking cessation care during pregnancy. The aim of this study was to systematically review all available global studies on the effectiveness of interventions in improving health providers' provision of smoking cessation care during pregnancy.

METHODS

Five databases were searched, Inclusion criteria included all intervention study types. Two reviewers screened abstracts and full texts independently. Interventions were characterized according to the Effective Practice Of Care taxonomy. Random-effects meta-analyses examined intervention effects on smoking cessation care components based on the 5As. Estimates were number of participants reporting each outcome, or mean score, transformed into Cohen's d. Crude meta-regressions, and meta-analysis subgrouping, were performed to examine whether intervention effects for 'Ask', 'Advise' and 'Assist' differed by intervention components.

RESULTS

Of 3165 manuscripts, 16 fulfilled inclusion criteria. Pooled analysis showed significant small to large intervention effects on the different care components (Cohen's d ranging from 0.47 for 'Ask' (95%CI 0.13-0.81) to 1.12 (95%CI 0.45-1.79) for 'Setting a quit date'). Crude meta-regression suggested that for 'Ask', having a theoretical basis may improve effectiveness (Cohen's d difference 0.62, 95% CI 0.12-1.1). Subgrouping the meta-analysis suggested that audit and feedback possibly increases intervention effectiveness for 'Advise' and 'Assist'.

CONCLUSION

Interventions designed to improve provision of smoking cessation care during pregnancy show a small increase in care components. Studies vary substantially in design, intervention components, and outcome measurement, impacting ability to synthesize available data. Audit and feedback and enhancing intervention design by using behaviour change theories may improve effectiveness.

REGISTRATION

PROSPERO CRD42016030143.

Seizing the 9-month moment: addressing behavioral risks in prenatal patients

OBJECTIVE

Our qualitative study explored prenatal care providers' methods for identifying and counseling pregnant women to reduce or stop smoking, alcohol use, illicit drug use, and the risk of domestic violence.

METHODS

We conducted six focus groups (five with OB/Gyn physicians, one with nurse practitioners and certified nurse midwives), total N=49, using open-ended questions. Investigators analyzed transcripts to identify and describe themes.

RESULTS

Three major themes emerged: (1) specific risk-prevention tactics or strategies exist that are useful during pregnancy; (2) some providers address patients' isolation or depression; and (3) providers can adopt a policy of "just chipping away" at risks. Specific tactics included normalizing risk prevention, using specific assessment techniques and counseling strategies, employing a patient-centered style of smoking reduction, and involving the family.

CONCLUSIONS

Providers generally agreed that addressing behavioral risks in pregnant patients is challenging. Patient-centered techniques and awareness of patients' social contexts help patients disclose and discuss risks.

PRACTICE IMPLICATIONS

Brief but routine assessment and risk reduction messages require little time of the provider, but can make a big difference to the patient, who may make changes later.