- 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. [More details in thesis abstract].
- 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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| Thumbnail | File | Description | Size | Format | |||
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| View Details Download | ATTACHMENT01 | Thesis | 25 MB | Adobe Acrobat PDF | View Details Download | ||
| View Details Download | ATTACHMENT02 | Abstract | 362 KB | Adobe Acrobat PDF | View Details Download |