Improving%20Implementation%20of%20Smoking%20Cessation%20Guidelines%20in%20Antenatal%20Care%20in%20NSW

1
Improving Implementation of Smoking Cessation
Guidelines in Antenatal Care in NSW

• Jo Longman, Megan Passey, Jenn Johnston and Cathy
  Adams

Sydney School of Public Health
2
In this presentation

• Background to this study
• Methods the Behaviour Change Wheel and
  Theoretical Domains Framework
• Findings
• Next steps

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Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006
3
Background

• 2011 - smoking in pregnancy in Australia 11.1
  (down from 17 in 2001)1
• Much higher in some groups e.g. Aboriginal women
  (53)2, women living in socioeconomic
  disadvantage1
• Pregnancy seen as a teachable moment for many
  women3,4
• Antenatal smoking cessation strategies
  effective5,6

Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006
4
Background

• National guidelines7 (2006) recommend following
  the 5 As
• Ask
• Advise
• Assess
• Assist
• Arrange follow-up
• for all pregnant women at the first visit
• for current smokers/quit within last 12
• months at every visit

Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006
5
Background
Evidence-practice gap8,9
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3A
Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006
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Aims

• To describe public antenatal care providers
  perceptions of the barriers and enablers to
  implementing the guidelines
• To develop behaviour-change intervention
  components to support antenatal clinicians to
  implement the guidelines

Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006
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Design
Semi-structured interviews with key
stakeholders R Semi-structured interviews with
midwives and obstetricians State-wide survey of
antenatal care providers Development and
trialling of intervention components
https//upload.wikimedia.org/wikipedia/commons/9/9
8/NSW_in_Australia_map.png
Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006
8
Method
Michie S, Atkins L West R The Behaviour Change
Wheel A Guide to Designing Interventions 2014
Silverback
Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006
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Theoretical Domains Framework (TDF)
Environmental context and resources
Beliefs about consequences
Beliefs about capabilities
Intentions
Memory, attention, decision making
Knowledge
Professional role and identity
Skills
Goals
Optimism
Social influences
Behavioural regulation
Reinforcement
Emotion
10
Design
Semi-structured interviews with key
stakeholders R Semi-structured interviews with
midwives and obstetricians State-wide survey of
antenatal care providers Development and
trialling of intervention components
https//upload.wikimedia.org/wikipedia/commons/9/9
8/NSW_in_Australia_map.png
Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006
11
Participants
Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006
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Theoretical Domains Framework (TDF)
Environmental context and resources
Beliefs about consequences
Beliefs about capabilities
Intentions
Memory, attention, decision making
Knowledge
Professional role and identity
Skills
Goals
Optimism
Social influences
Behavioural regulation
Reinforcement
Emotion
13
Contextual Findings

• Generally participants familiar with the 5As
  process if not the language
• Covered at initial visit but less so in
  subsequent visits
• Commonly a focus on Ask and Advise but less on
  Assess, Assist and Arrange follow-up
• Complex interplay of barriers and enablers

Behavioural regulation
Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006
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Findings10, 11,12
Environmental context and resources

• Systems as barriers and enablers
• Time restrictions as a barrier
• Lack of training
• Dont want to damage the relationship

Behavioural regulation
Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006
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Findings - Systems
Environmental context and resources

• Systems as enablers and barriers
• Electronic database was a potential enabler
• prompts/reminds clinicians to cover the topic
• provides a scaffold for which areas to cover
• is was a normalised part of the initial visit
• system gave clinicians a licence to ask
• at first, but not subsequent, visits

... for everyone, and then it didnt become
like you were picking on somebody. (midwife)
Behavioural regulation
Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006
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Findings
Environmental context and resources
It is fascinating. Talking about it I'm feeling
quite appalled at our system really. (manager)
Behavioural regulation
Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006
17
Findings
Environmental context and resources

• Time restrictions as a barrier
• Everyone feeling stretched for time outside of
  models where there is genuine flexibility
• Range and depth of topics required
• Smoking cessation perceived as a either or
  situation if you include smoking cessation in
  your visit then something has to be omitted to
  compensate for that
• What clinicians DO with the time they have
• Lack of time an excuse for not tackling a
  difficult conversation

Behavioural regulation
Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006
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Findings
Skills

• Little recent skills training (including new
  grad)
• Main skills gaps
• Talking about smoking without damaging the
  relationship
• Handling conflict (eye rolling)
• Assisting
• assisting women who are not ready, unsure
  about quitting, cant quit or have had
  unsuccessful previous quit attempts
• Enablers
• Some clinicians highly experienced and skilled

Behavioural regulation
Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006
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Findings
Professional role and identity

• Midwives unequivocal that smoking cessation
  support (all 5 As) a part of their role
• However smoking cessation support part of the
  role for clients who are motivated to quit?
• Some obstetricians more equivocal
• first 2 As

the women really have to be ready to give up"
(midwife)
Behavioural regulation
"Is there any reason why obstetricians are right
in saying its not our role?  Probably not.
(obstetric manager)
Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006
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Next steps

• Cross-sectional survey
• Design intervention components
• Map domains on to intervention functions
• Select relevant modes of delivery
• Design evaluation
• Select outcome measuresHS exposure

Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006
21
Summary

• Evidence-practice gap in smoking cessation in
  pregnancy is an international problem.
• The findings of this study will help develop
  intervention components to support clinicians in
  implementing the guidelines.
• Regular SHS exposure

Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006
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Thanks

• The research team and advisory committee include
  service managers, clinicians and policy makers.
• The team are collaborating with Ministry staff
  developing the next iteration of the database to
  implement changes to support guideline
  implementation.
• Funding
• NSW Cancer Institute Fellowship
• National Health and Medical Research Council of
  Australia Fellowship
• Sydney Medical School Foundation
• University Centre for Rural Health Research
  Development Award
• University of Sydney School of Public Health
  Academic Development Award
•  

Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006
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References

1. Scollo M, Winstanley M. Tobacco in Australia
   Facts and Issues. Melbourne Cancer Council
   Victoria 2012. Available from
   http//www.tobaccoinaustralia.org.au
2. Johnston V, Thomas DP, McDonnell J, Andrews RM.
   Maternal smoking and smoking in the household
   during pregnancy and postpartum findings from an
   Indigenous cohort in the Northern Territory.
   Medical Journal of Australia 2011194556-9.
3. McBride CM, Emmons KM, Lipkus IM. Understanding
   the potential of teachable moments the case of
   smoking cessation. Health Educ Res
   200318(2)156-70.
4. Ockene J, Ma Y, Zapka J, et al. Spontaneous
   cessation of smoking and alcohol use among
   low-income pregnant women. Am J Prev Med
   200223(3)150-9.
5. Lumley J, Chamberlain C, Dowswell T, et al.
   Interventions for promoting smoking cessation
   during pregnancy. Cochrane Database Syst Rev
   2009(3)CD001055
6. Chamberlain C, O'Mara-Eves A, Oliver S, et al.
   Psychosocial interventions for supporting women
   to stop smoking in pregnancy. Cochrane Database
   Syst Rev 2013(10)Art. No. CD001055.
7. NSW Department of Health. National clinical
   guidelines for the management of drug use during
   pregnancy, birth and early development years of
   the newborn. Sydney NSW Department of Health
   2006.

Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006
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References

1. Tran ST, Rosenberg KD, Carlson NE. Racial/ethnic
   disparities in the receipt of smoking cessation
   interventions during prenatal care. Matern Child
   Health 2010 14 901-909
2. Perlen S, Brown SJ, Yelland J. Have guidelines
   about smoking cessation support in pregnancy
   changed practice in Victoria, Australia? Birth
   2013 40(2)81-87.
3. Colomar M, Tong V, Morello P, Farr S et al
   Barriers and promoters of an evidence-based
   smoking cessation counselling during prenatal
   care in Argentina and Uruguay Matern Child
   Health J 2015 19 1481-1489
4. Herberts C Sykes C Midwives perceptions of
   providing stop smoking advice and pregnant
   smokers perceptions of stops smoking services
   within the same deprived area of London J
   Midwifery Womens Health 2012 57 67-73
5. Fleming K, Graham H, McCaughan D, Angus K,
   Sinclair L and Bauld L Health professionals
   perceptions of the barriers and facilitators to
   providing smoking cessation advice to women in
   pregnancy and during the post-partum period a
   systematic review of qualitative research BMC
   Public Health 2016 16290

Oberg et al. 2011 US Department of Health 2014
US Surgeon General 2006