- Title
- Improving health providers’ management of smoking in Australian Indigenous pregnant women
- Creator
- Bar-Zeev, Yael
- Relation
- University of Newcastle Research Higher Degree Thesis
- Resource Type
- thesis
- Date
- 2019
- Description
- Research Doctorate - Doctor of Philosophy (PhD)
- Description
- Globally, tobacco use is the leading cause of morbidity and mortality, causing an annual death rate of seven million people. In Australia, tobacco use is responsible for 9% of the total burden of disease. Smoking during pregnancy remains a significant public health problem for specific population groups, causing miscarriage, stillbirth, low birth weight and more. Psychosocial interventions such as behavioural counselling have been shown to be effective. Clinical guidelines in Australia recommend using the 5As approach: Ask about smoking status, Advise briefly to quit, Assess nicotine dependence and motivation to quit, Assist as needed (including behavioural counselling and nicotine replacement therapy [NRT] if required), and Arrange follow-up and referral to smoking cessation support services. NRT is recommended if the woman is unable to quit using only behavioural counselling, with oral NRT considered as first line. Aboriginal and Torres Strait Islander pregnant women have the highest smoking rates in Australia at 43%, facing multiple barriers to quitting smoking, including lack of adequate support from health providers. Health providers also face many barriers to support pregnant women to quit smoking, on an individual and systematic organisational level. To date, very few interventions have tried to improve health providers’ management of smoking with Aboriginal and Torres Strait Islander pregnant women. Those that have either did not use rigorous research methods or suffered from multiple implementation challenges. The aim of this thesis was to explore health providers’ practices regarding smoking cessation care during pregnancy, barriers to the provision of smoking cessation care and methods for improving health providers’ care, and to test an evidence-based behaviour change intervention to improve health providers’ provision of smoking cessation care to pregnant Aboriginal and Torres Strait Islander women. Papers one to five explore health providers’ provision of smoking cessation care during pregnancy in general. Some data for Aboriginal and Torres Strait Islander pregnant women who smoke is also presented. The results of the first five studies were used to refine the development of a multi-component pilot intervention: the Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy intervention for implementation in Aboriginal medical services. Papers six to eight explore the development of the intervention resources, the intervention protocol and the effect of this intervention on health providers’ smoking cessation care. Three related theoretical frameworks were drawn on throughout the research: the Theoretical Domains Framework (TDF), Behaviour Change Wheel (BCW) and the COM-B (Capability, Opportunity, Motivation–Behaviour) model for behaviour change. Paper one, “Opportunities Missed: A Cross-Sectional Survey of the Provision of Smoking Cessation Care to Pregnant Women by Australian General Practitioners and Obstetricians”, presents the results of a national cross-sectional survey of 378 general practitioners (GPs) and obstetricians about their knowledge, attitudes and practices providing smoking cessation care to pregnant women. Data from this survey revealed low levels of provision of several smoking cessation care components (“Assess”, “Assist” and “Arrange”), with only 15.6% of GPs and obstetricians reporting “often and/or always” performing all of the recommended 5As. Specifically, GPs and obstetricians reported that they lacked time, resources and confidence in their ability to prescribe NRT during pregnancy, and lacked optimism that their intervention would be effective. Paper two, “Clinician Factors Associated with Prescribing Nicotine Replacement Therapy in Pregnancy: A Cross-Sectional Survey of Australian Obstetricians and General Practitioners”, reports the results from the same cross-sectional survey mentioned in paper one, exploring GPs’ and obstetricians’ NRT prescribing rates and factors that might influence this. Overall, 25% of GPs and obstetricians reported “never” prescribing NRT, with nearly 50% reporting they would “never” prescribe combination NRT (NRT patch plus an oral NRT). GPs had higher odds of prescribing NRT compared to obstetricians. Other factors that significantly increased the odds of NRT prescription were reading the Royal Australian College of General Practitioners (RACGP) guidelines, confidence in their ability to prescribe NRT and viewing NRT as safe, effective and with good patient adherence. Paper three, “Overcoming Challenges to Treating Smoking during Pregnancy – A Qualitative Analysis of Australian General Practitioners’ Barriers and Facilitators”, reports on semi-structured qualitative interviews that were conducted with 19 GPs, aiming to explore their management of smoking during pregnancy in greater depth and what would enable them to improve their smoking cessation support to pregnant women. GPs were recruited from the cross-sectional survey participants and from those attending a national GP conference. Participants reported they lacked communication skills to provide pregnant patients adequate support for quitting, focusing on providing information on smoking harms and discussing treatment options only with patients who reported an interest in quitting. Lack of time, NRT cost, previous negative experiences with NRT and safety concerns, being unfamiliar with the Quitline process and uncertainty over its suitability (specifically for Aboriginal and Torres Strait Islander peoples) were all perceived as additional challenges. Participants reported needing clear detailed guidelines, with visual resources they could use to discuss treatment options with patients. Paper four, “Nicotine Replacement Therapy for Smoking Cessation in Pregnancy – A Narrative Review”, provides an overview of the current guidelines regarding NRT use in pregnancy, while considering the existing evidence base on NRT safety, efficacy and effectiveness during pregnancy. Animal models show that nicotine is harmful to the foetus, especially for brain and lung development, but human studies have not found any harmful effects on foetal and pregnancy outcomes. Previous studies have used NRT doses that might have been too low and not have adequately accounted for the higher nicotine metabolism during pregnancy, and thus not sufficiently treating withdrawal symptoms. Nonetheless, studies of efficacy and effectiveness in the real world suggest that NRT use during pregnancy increases smoking cessation rates. Current national clinical guidelines from Australia, the United Kingdom, New Zealand and Canada recommend that if women are unable to quit smoking with behavioural interventions alone, they should be offered NRT in addition to behavioural counselling. The guidelines also impose many restrictions on NRT prescription during pregnancy and do not provide practical detailed guidance on when to initiate NRT and how to titrate the dosage. Pragmatic suggestions for clinical practice are made, including an approach for initiating and titrating NRT dosage during pregnancy and for discussing the risks versus benefits of using NRT in pregnancy with the pregnant patient and her partner. Paper five, “Improving Health Providers’ Smoking Cessation Care in Pregnancy: A Systematic Review and Meta-Analysis”, reviews the data from all published interventions aimed to improve health providers’ smoking cessation care during pregnancy. To be included, the intervention studies needed to collect data on the health providers’ performance. Overall, 16 studies describing 14 interventions were included – 10 used a quasi-experimental design (pre–post), with only six studies using a randomised controlled trial (RCT) design. Using the Cochrane Effective Practice of Care (EPOC) taxonomy of intervention components, the review found that the median number of intervention components reported by studies was two (range 1–6). The most common intervention components used were training (93%, n=13), educational resources (64%, n=9) and reminders (57%, n=8). Studies used a variety of outcome measures, with different data collection methods (such as self-report through survey, women’s report on the health providers’ care, audit of medical records or recordings of medical consultations), affecting the ability to synthesise the data. Specifically, the “Assist” or “Provide smoking cessation support” component of care was ill defined with vast variability between studies. Meta-analysis of the different smoking cessation care components (according to the 5As) showed a small significant increase in the provision of all smoking cessation care components. The review suggests that use of a behaviour change theory to guide intervention development, and inclusion of audit and feedback, increases the likelihood of intervention effectiveness in improving health providers’ provision of certain smoking cessation care components. Paper six, “Assessing and Validating an Educational Resource Package for Health Professionals to Improve Smoking Cessation Care in Aboriginal and Torres Strait Islander Pregnant Women”, describes a multi-centre community-based participatory research study. This study aimed to assess a collaboratively developed educational resource package to aid health providers’ smoking cessation care in pregnant Aboriginal and Torres Strait Islander women. A panel of eight experts with complementary expertise provided input and suggestions to aid simplicity and usefulness of the resources. Staff members from three Aboriginal medical services in New South Wales (NSW), Queensland (Qld) and South Australia (SA) scored each of the patients’ resources using the “Suitability of Material” scoring method, finding that all received adequate or superior scoring. Average readability was grade 6.4 for patient resources (range 5.1–7.2; equivalent to ages 10–13 years) and 9.8 for health provider resources (range 8.5–10.6; equivalent to ages 13–16 years). Content analysis from focus groups with health providers from the three Aboriginal medical services revealed four themes including “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 (SCAAP), and resources were adjusted accordingly for inclusion in the ICAN QUIT in Pregnancy multi-component intervention. Paper seven, “The Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy Pilot Study Protocol: A Feasibility Step-Wedge Cluster Randomized Trial to Improve Health Providers’ Management of Smoking during Pregnancy”, describes the protocol of a step-wedge cluster randomised pilot study: the ICAN QUIT in Pregnancy intervention. This protocol described an intervention aiming to improve health providers’ provision of evidence-based, culturally responsive smoking cessation care to pregnant Aboriginal and Torres Strait Islander smokers. Six Aboriginal medical services were randomised into three clusters for implementation. Clusters received the intervention staggered by one month. The intervention included a three-hour training webinar for health providers, educational resource packages for health providers and pregnant women, free oral NRT for pregnant women and audit and feedback on health providers’ performance. Health providers would complete a cross-sectional survey pre training and post training. Health providers’ outcomes would include changes in self-reported knowledge, attitudes and practices after receiving the intervention. Paper eight, “Improving Smoking Cessation Care in Pregnancy at Aboriginal Medical Services: ICAN QUIT in Pregnancy Step-Wedge Cluster Randomized Pilot Study”, presents the pilot study outcomes of changes in health providers’ knowledge, attitudes and practices. Of 93 eligible health providers, 50 consented to the trial (54%), 45 completed the pre-intervention survey (90%) and 20 completed the post-intervention survey (40%). About 42% (n=39) of health providers participated in the webinar training. Health providers’ knowledge was measured using two composite scores – one calculated using all 24 true/false statements and the other derived from 12 NRT-specific statements. Mean knowledge composite scores improved significantly from pre to post (78% vs 84% correct, p=0.011). The mean NRT-specific knowledge composite score also improved significantly (68% vs 79% correct, p=0.004). Self-assessment of 24 attitudes to providing smoking cessation care was measured using a 5-point Likert scale (Strongly Disagree to Strongly Agree). Two composite mean scores were calculated –one for 15 general smoking cessation care attitudes and the other for seven NRT-specific attitudes. The mean attitude composite score improved significantly (3.65 [SD 0.4] to 3.87 [SD 0.4]; p=0.017). The mean NRT-specific attitudes composite score also improved significantly (3.37 [SD 0.6] to 3.64 [SD 0.7]; p=0.005). Self-reported provision of smoking cessation care components was measured on a 5-point Likert scale (Never to Always); none of the practices improved significantly, including the prescribing of NRT. In summary, increasing health providers’ provision of smoking cessation care to pregnant Aboriginal and Torres Strait Islander women is a significant priority in Australia. This body of work highlights that currently, health providers are lacking in their provision of smoking cessation care, specifically in their support for pregnant Aboriginal and Torres Strait Islander women to quit smoking. Particularly, the provision of the “Assist” smoking cessation component was low, including the prescription of NRT. Multiple barriers exist and include lack of knowledge, skills (especially communication skills), time, resources and lack of optimism. Guidelines do not provide clear guidance, including the optimal timing for initiating NRT and titrating the dosage. The pilot intervention tested within this thesis showed promising initial results, with health providers significantly improving their knowledge and attitudes, although this did not translate into improved practices. Several strategies might enhance the effectiveness of the intervention and should be tested in a larger and adequately powered trial. The complex nature of tobacco smoking, and considering its historical and social context in Aboriginal communities, suggests that wider and more intensive interventions are needed.
- Subject
- smoking cessation care; pregnancy; health providers; Aboriginal and Torres Strait Islander; thesis by publication
- Identifier
- http://hdl.handle.net/1959.13/1402480
- Identifier
- uon:35033
- Rights
- Copyright 2019 Yael Bar-Zeev
- Language
- eng
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