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Improving Implementation of Smoking Cessation Guidelines in Antenatal Care in NSW

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. In this presentation:. Background to this study

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Improving Implementation of Smoking Cessation Guidelines in Antenatal Care in NSW

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  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 https://www.google.com.au/search?as_st=y&tbm=isch&hl=en&as_q=pregnant+smoke&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fmc#as_st=y&hl=en&tbs=sur:fmc&tbm=isch&q=pregnant+smoking+drinking&imgrc=Cxk-Tf8OvI131M%3A 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 https://www.google.com/search?as_st=y&tbm=isch&hl=en&as_q=problem&as_epq=&as_oq=&as_eq=&cr=&as_sitesearch=&safe=images&tbs=sur:fc#imgrc=Cc_E80Ms1xVYBM%3A Oberg et al. 2011; US Department of Health 2014; US Surgeon General 2006

  6. 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

  7. 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/9/98/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

  9. 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/9/98/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

  12. 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

  14. Findings10, 11,12 • Environmental • context and resources • Systems as barriers and enablers • Time restrictions as a barrier • Lack of training • Don’t want to damage the relationship Behavioural regulation Oberg et al. 2011; US Department of Health 2014; US Surgeon General 2006

  15. 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 didn’t become – like you were picking on somebody. (midwife)” Behavioural regulation Oberg et al. 2011; US Department of Health 2014; US Surgeon General 2006

  16. Findings • Environmental • context and resources “It is fascinating. Talking about it I'm feeling quite appalled at our system really.” (manager) I’ll go into the referral thing, it’s just got – it hasn’t got anything about smoking on it, which is really ludicrous (midwife). 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’ “And I wonder, too, this, ‘oh, we don't have time’, is really another way of saying, ‘Look, I really don't know what to do with this.’” (manager) “…massive” (manager) Behavioural regulation Oberg et al. 2011; US Department of Health 2014; US Surgeon General 2006

  18. 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, ‘can’t’ 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

  19. 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 it’s not our role?  Probably not.” (obstetric manager) Oberg et al. 2011; US Department of Health 2014; US Surgeon General 2006

  20. 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

  22. 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

  23. References • ScolloM, Winstanley M. Tobacco in Australia: Facts and Issues. Melbourne: Cancer Council Victoria; 2012. Available from: http://www.tobaccoinaustralia.org.au • 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 2011;194:556-9. • McBride CM, Emmons KM, Lipkus IM. Understanding the potential of teachable moments: the case of smoking cessation. Health Educ Res 2003;18(2):156-70. • OckeneJ, Ma Y, Zapka J, et al. Spontaneous cessation of smoking and alcohol use among low-income pregnant women. Am J Prev Med 2002;23(3):150-9. • Lumley J, Chamberlain C, Dowswell T, et al. Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev 2009(3):CD001055 • 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. • 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

  24. References • 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 • 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. • 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 • HerbertsC & 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 • 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; 16:290 Oberg et al. 2011; US Department of Health 2014; US Surgeon General 2006

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