Factors associated with provision of smoking cessation support to pregnant women – a cross-sectional survey of midwives in New South Wales, Australia

Smoking is the single most important preventable cause of adverse infant outcomes including stillbirth, preterm birth, low birth weight, asthma, childhood respiratory infections and adult cardiovascular disease [1‐4]. These harms are significantly reduced if women stop smoking during pregnancy [2]. Many pregnant women are highly motivated to quit smoking, but often face significant challenges in doing so, including lack of support from health professionals [5]. Psychosocial interventions to support pregnant women to quit are effective [2].

In Australia, clinical guidelines recommend routine and repeated assessment of smoking status for all pregnant women with ongoing support for quitting and staying quit, using the evidence-based 5As framework (Ask, Advise, Assess, Assist and Arrange follow-up) [6]. This means that, at every antenatal visit, the woman should be Asked her smoking status. If she is a current smoker, or has recently quit smoking, the remaining As are provided, as relevant. The woman should be Advised that the best thing she can do for her baby is to stop smoking, with discussion of the benefits of doing so. Her nicotine dependence and willingness to quit should be Assessed. She should then be Assisted, for example, encouraging her to stop smoking using motivational interviewing techniques, and providing resources and referral, as appropriate. Finally, the clinician should Arrange follow-up to provide additional support and monitor progress [6]. The 5As framework is effective, considered to be best practice and widely adopted in policy and practice both in Australia and internationally [7, 8]. However, implementation of the 5As continues to be poor with many women not provided with assistance for quitting [9, 10]. In New South Wales (NSW), only 46% of women who smoked in pregnancy recalled being told about quitting programs [11]. Qualitative research has confirmed gaps in care, especially with Assisting and Arranging follow-up [12]. The failure to deliver smoking cessation support (SCS) is a critical missed opportunity to support cessation.

Changing the practice of health care providers requires the use of a comprehensive theory-driven and evidence-based approach which addresses specific behaviours in context [13]. One such approach, the ‘Behaviour Change Wheel’ (BCW), has demonstrated effectiveness in changing healthcare delivery [14]. The BCW approach starts with identification of the target behaviour for change, then development of a clear understanding of the barriers to its implementation. The BCW categorises barriers to implementing behaviours under three main constructs: Capability (Psychological or physical ability to enact the behaviour, e.g. having the required skills and knowledge); Opportunity (Physical and social environment that enables the behaviour, e.g. having the required resources to undertake the behaviour); and Motivation (Reflective and automatic mechanisms that activate or inhibit the behaviour, e.g. perceiving the behaviour as an important part of their role) [14]. Once the barriers to the behaviour have been identified and understood, the intervention is developed by mapping the identified barriers to intervention functions and behaviour change techniques [14]. Further detail on this process can be found in ‘The Behaviour Change Wheel: A Guide to Designing Interventions’. [14].

The Theoretical Domains Framework (TDF) is a validated, comprehensive framework for identifying barriers and enablers to implementation [15] and can be used in the initial ‘diagnostic’ phase of the BCW process. The TDF was validated with 37 experts in behaviour change theory, using closed and open sort tasks with testing of the extent of replication by discriminant content validation and fuzzy cluster analysis [15]. It covers 14 domains of theoretical constructs (Knowledge, Skills, Memory, Attention and Decision Processes, Beliefs about Capabilities, Beliefs about Consequences, Optimism, Intentions, Goals, Emotion, Professional Role and Identity, Social Influences, Environmental Context and Resources, Behavioural Regulation, and Reinforcement) [15]. The TDF has previously been used to identify barriers to implementation, including barriers to providing SCS to women [16], with subsequent development of an effective intervention [17].

A cross-sectional on-line anonymous survey of midwives providing antenatal care in the public health system in NSW, Australia, was undertaken over 4 weeks in late 2016. Ethical approval was provided by the Hunter New England Human Research Ethics Committee (Ref. 14/06/18/5.04).

In this paper we have assessed midwives self-reported provision of SCS to pregnant women, explored their perceptions of the barriers and enablers to providing this support and examined the relationship between these barriers and enablers and the support provided. This allowed identification of the most critical barriers and enablers that need to be addressed to improve delivery of effective SCS. Importantly, in developing our questionnaire, we used a comprehensive and validated theoretical framework, the TDF, which will facilitate the process of identifying intervention components using the BCW process [14]. The factor analyses of the two main components of the questionnaire identified three 5As factors and nine barrier/enabler factors with the factors in each analysis explaining approximately two thirds of the variance, all composite factors having high Cronbach’s alpha, and the structures having conceptual coherence, thus providing evidence for the validity of the questionnaire.

Asking and Assessing (especially nicotine dependence) were more commonly performed than Advising, Assisting and Arranging follow-up, and smoking was more commonly addressed at the initial visit than subsequent antenatal visits (Fig. 1). By contrast, other studies have found that Asking smoking status and giving brief Advice to quit smoking were more commonly performed than Assessing, providing Assistance or Arranging follow-up [19, 21‐24]. In the case of provision of advice, this difference may result from the wording of our question (‘How often do you give clear, strong messages urging every pregnant smoker to quit?’). Most other studies have asked about providing ‘brief advice’ which may account for the higher positive response. Chang et al audio-recorded 116 interactions at the first obstetric visit and identified that obstetricians Asked about smoking in 98% of visits but only provided Advice to quit in 31% of visits. In only six of the 116 cases was the Advice considered to be ‘strong’ advice, and in only four cases was it ‘clear, strong and personalised’. [25].

The high rate of Assessing nicotine dependence is likely due to the clinical information system used by midwives, which made assessment of nicotine dependence (time to first cigarette and cigarettes/day) mandatory fields for all smokers. The inclusion of these mandatory fields in the clinical information system also explains the lack of variability in response to these questions and highlights the importance of electronic information systems in providing prompts for clinical activity [26].

.The finding that smoking is more frequently addressed at the initial visit than at subsequent visits is consistent with multiple other studies with both midwives and obstetricians [12, 22, 24, 27, 28]. Offering personalised support for cessation repeatedly throughout pregnancy is valuable as it provides a consistent message for women that midwives are concerned about them and their smoking [29, 30].

.The factor analysis of the 5As questions identified three factors, with one main factor (named ‘Helping’) including all the Advice, Assist and Arrange follow-up items, with strong factor loadings (all > 0.58). The other two factors, ‘Assessing Quitting’ and ‘Assessing Dependence’, related to assessing women’s behaviour. While making assessments is useful for clinicians’ understanding of the woman’s dependence and attitudes, they provide no support to the woman for an actual quit attempt. Unfortunately, although it is Assisting and Arranging follow-up that are critical to successful quitting [31‐33], ,the items in the ‘Helping’ factor were least likely to be performed (‘Always’ performed by 30 to 45% of survey respondents).

The first factor identified in the analysis of barriers was ‘Capability’, which included all the knowledge, skills and confidence (beliefs about capabilities) items. Participants reported poorer knowledge, skills and confidence related to Assisting than Assessing, and more commonly agreed with knowledge statements than with those for skills and confidence – consistent with both their reported behaviour and other research [12, 21, 22]. Importantly, the ‘Capability’ factor was significantly associated with ‘Helping’ women, and thus, ascertaining the items in ‘Capability’ with lesser agreement (skills, confidence and adequate training) helps to identify potential components for interventions. Skills training for health professionals improves professional performance and continuous abstinence [34].

.The ‘Work Environment’ factor was significantly associated with both ‘Helping’ and ‘Assessing quitting’. There was considerable spread in the responses to the items included in ‘Work Environment’, although there was greater agreement with the items related to capacity of the service and pamphlets and resources, than those related to values and social influence. The item with the lowest agreement related to champions within the service, suggesting that developing local cessation champions would be beneficial [35]. Champions may impact the culture of the organisation, motivating other staff, supporting staff training, and monitoring service provision and client outcomes [35].

.The ‘Personal priority’ factor was also associated with ‘Helping’. There was little disagreement with any of the three items in this factor, however, the item about placing a high priority on smoking cessation was least well supported. Qualitative research has identified that a perceived lack of time to address smoking, combined with a perception that smoking was a ‘private’ issue resulted in smoking cessation being a low priority in some circumstances [12]. One approach to persuading clinicians to prioritise smoking cessation is to ‘reframe’ their perception of smoking by drawing parallels with other conditions and their approach to them [14]. This could involve education about the comparative health consequences of different problems (e.g. smoking vs diabetes), combined with a comparison of the clinical responses and management of each.

The ‘Intentions and Memory’ factor was also important in predicting ‘Assessing quitting’. There was stronger agreement with intentions than remembering, with lesser agreement for intentions and memory after the first visit. This suggests that prompts and reminders could be beneficial, particularly focused on subsequent visits – either in the form of enhanced electronic reminders or required fields, or other aids such as flowcharts and clinical pathways displayed in the clinic. As discussed earlier, the high rate of assessment of nicotine dependence identified in this study is likely due to design features of the clinical information system in use.

The final factor significantly related to ‘Assessing quitting’ was ‘Negative perceptions’. These items were reverse coded, indicating that stronger disagreement with these statements was associated with greater assessment of interest in quitting smoking. It is not surprising that a perception that supporting smoking cessation is difficult and not likely to be successful is associated with lesser assessment of interest in quitting. However, with adequate training, managerial support, provision of useful resources and referral options, this negative perception may be changed.

In this study, respondents more commonly reported Asking and Assessing than Advising, Assisting, or Arranging follow-up. Three 5As factors were identified– ‘Helping’, ‘Assessing quitting’ and ‘Assessing dependence’. Responses to barrier/enabler items showed greater knowledge, skills, intentions, and confidence with Assessment than Assisting; endorsement for SCS as a priority and part of midwives’ professional role; and gaps in training and organisational support for SCS. Nine barrier/enabler factors were identified. Of these, the factors of ‘Capability’; ‘Work Environment’ and ‘Personal priority’ predicted ‘Helping’.

The use of the TDF enabled a systematic and comprehensive approach to identifying barriers to providing SCS, and the multivariate models allowed assessment of the main contributors to poor implementation. This process, including the use of the TDF, facilitates mapping barriers to intervention components using the BCW [14]. Combined with qualitative data already published [12], these results have been mapped to specific, tailored intervention components and behaviour change techniques to form a comprehensive intervention to improve implementation of SCS.