Assignment: Healthy Information Technology
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CE 1.5 HOURS Continuing Education ORIGINAL RESEARCH Downloaded from https://journals.lww.com/ajnonline by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3d0gbN0a5/T8FXXKiOa10N4t/oKiBVqDrgi05j1xKto8= on 09/18/2018 The Experiences of Pregnant Smokers and Their Providers Study findings suggest ways to better address tobacco use. S moking during pregnancy is one of the moststudied risk factors in obstetrics. Simpson’s 1957 study of the effect of smoking on infant birth weight and incidence of prematurity was just the first of many studies identifying a host of adverse outcomes.1 The deleterious effects of smoking on pregnancy and fetal and infant health, as well as on the long-term health of the child, have been well established (see Evidence for Adverse Effects of Tobacco Use in Pregnancy). In general, tobacco use is the single most preventable cause of morbidity and mortality in the United States, across all populations.2 According to the Centers for Disease Control and Prevention (CDC) and other sources, prevalence is highest among people between the ages of 24 and 64, those living below the poverty line, those who are unmarried, those living in rural areas, and those having a high school equivalency degree or less education.2-5 In 2010, the U.S. Department of Health and Human Services launched its Healthy People 2020 initiative, which identifies smoking cessation during pregnancy as an objective within the “tobacco use” topic area and sets a target of having at least 30% of pregnant smokers quit during their first trimester.6 Data from earlier years show that in 2015, 17% of pregnant women between the ages of 18 and 49 stopped smoking, an increase from the 11.3% who did so in 2005 but less than the 18.9% who did so in 2010.6 The CDC has reported that in 2010, 54% of women who smoked reported quitting by their last trimester.7 Unfortunately, smoking relapse rates for the first year following childbirth remain high, with estimates ranging from 50% to 80%.8 The CDC has also indicated that 10.7% of women nationwide 24 AJN ▼ June 2017 ▼ Vol. 117, No. 6 and 11.4% in New York State reported smoking during their last trimester.7 But smoking rates can vary greatly depending on the specific geographic location. According to data from the New York State Department of Health, the 2014 rates for pregnant women in some upper New York State counties were higher, including 26% in Broome County, 37% in Chemung County, and 32% in Chenango County.9 Approaches to cessation. Because smoking is a complex behavior with physiologic, cognitive, behavioral, and emotional components, interventions addressing cessation must have a multifaceted approach. Treating tobacco use is an expected responsibility of good nursing care, and is endorsed by the American Nurses Association.10 In 2008, the U.S. Public Health Service (USPHS) issued Treating Tobacco Use and Dependence, a clinical practice guideline that has become the gold standard for initiating smoking cessation treatment.11 Its five-step approach (also known as the “5 A’s”) involves asking patients about tobacco use, advising tobacco users to quit, assessing their readiness to quit, assisting with quitting, and arranging follow-up care.11 The guideline recommends offering smoking cessation interventions whenever possible. Although there are numerous challenges to successful implementation12—indeed, addressing smoking history itself can be a barrier13—smoking cessation interventions have been shown to be effective in “reducing continued smoking into late pregnancy and in improving infant health.”14 That said, a Cochrane review by Lumley and colleagues of 72 randomized controlled trials of intervention strategies, conducted between 1975 and 2008, found only a 3% to 6% difference in the combined maximum effect of ajnonline.com By Geraldine Rose Britton, PhD, RN, FNP, Rosemary Collier, PhD, RN, Sean McKitrick, PhD, Lori Marie Sprague, MS, RN, Joyce Rhodes-Keefe, MS, RN, Ann Feeney, PhD, RN, CRNP, CNM, and Gary D. James, PhD ABSTRACT Background: The U.S. Department of Health and Human Services’ initiative Healthy People 2020 targets tobacco use, including smoking during pregnancy, as a continuing major health concern in this country. Yet bringing the U.S. Public Health Service’s 2008 clinical practice guideline, Treating Tobacco Use and Dependence, into routine prenatal care remains challenging. Our previous nurse-managed intervention study of rural pregnant women found no significant cessation effect and significant discordance between selfreported smoker status and urinary cotinine levels. Purpose: The overall purpose of this follow-up study was to increase our understanding of the experiences of pregnant smokers and their providers. No qualitative studies could be found that simultaneously explored the experiences of both groups. Design and methods: This qualitative descriptive study used focus group methodology. Nine focus groups were held in two counties in upper New York State; six groups consisted of providers and three consisted of pregnant women. Four semistructured questions guided the group discussions, which were audiotaped and transcribed verbatim. Transcripts were read and coded independently by six investigators. Themes were identified using constant comparative analysis and were validated using the consensus process. Results: The total sample consisted of 66 participants: 45 providers and 21 pregnant women. Most of the providers were white (93%) and female (93%). A majority worked as RNs (71%); the sample included perinatal and neonatal nursery nurses, midwives, and physicians. The pregnant women were exclusively white (reflecting the rural demographic); the average age was 24 years. All the pregnant women had smoked at the beginning of their pregnancies. Four common themes emerged in both the provider and the pregnant women groups: barriers to quitting, mixed messages, approaches and attitudes, and program modalities. These themes corroborate previous findings that cigarette smoking is used for stress relief, especially when pregnancy itself is a stressor, and that pregnant women may feel guilty but don’t want to be nagged or preached to. Conclusions: These results have implications for how smoking cessation programs for pregnant women should be designed. Health care providers need to be cognizant of their approaches and attitudes when addressing the subject of smoking cessation. Specific educational suggestions include “putting a face” to the issue of tobacco use during pregnancy. More research is needed on how best to implement the 2008 clinical practice guideline in specific populations. Keywords: clinical practice guideline, pregnancy, smoking, smoking cessation, tobacco use interventions to promote cessation and no significant effect on relapse.15 Similarly, a systematic review of counseling effects on perinatal cessation found only a 4% absolute difference.16 And a recent update of the Cochrane review found that the cessation interventions in the 20 newest studies had a lower effect size (3%).17 The authors stated: “Trials where the interventions became part of routine pregnancy care did not appear to help more women to quit, which suggests there are challenges to translating this evidence into practice.”17 Several studies have attempted to address the specific needs of pregnant smokers by exploring their experiences. In a systematic review of 26 qualitative studies on pregnant women’s experiences of smoking during pregnancy, Flemming and colleagues identified themes of guilt and concealment, as well as “a fundamental tension between the twin identities of smoker and expectant mother.”14 One barrier to quitting may be that interventions are viewed as ajn@wolterskluwer.com inaccessible and ineffective,18 perhaps because of a perception of health care providers as insensitive or judgmental.19, 20 External stressors may exacerbate the inherent stress of pregnancy. Women who smoke may face unique challenges related to their geographic location, socioeconomic status, and familial relationships, among other factors. For example, in a study of 15 low-income African American women, participants cited economic hardship and living in violent neighborhoods as among the stressors outside their control, and felt that smoking helped alleviate that stress.21 In other studies, pregnant women also cited social isolation as a source of stress, such as may result from withdrawing from the working world or from the social act of smoking, or from feeling isolated in relationships if family members and friends continue to smoke.20, 22 Few studies have explored the experiences of both pregnant smokers and their providers. AJN ▼ June 2017 ▼ Vol. 117, No. 6 25 Our previous study. In an earlier study of 194 pregnant rural smokers enrolled in a nurse-managed program called Smoke Free Baby & Me, we found significant differences in validated smoking cessation at the postpartum visit among participants who had quit just before their first prenatal visit, but no differences among those who were current smokers.23 The program was based on the 5 A’s and was integrated into real-world routine perinatal care. The findings support the Cochrane reviews’ recommendations that better psychosocial support for smoking cessation and a better understanding of how to integrate the Evidence for Adverse Effects of Tobacco Use in Pregnancy Pregnancy Effects •• Abruptio placenta Meyer MB, Tonascia JA. Am J Obstet Gynecol 1977; 128(5):494-502. Salihu HM, Wilson RE. Early Hum Dev 2007;83(11): 713-20. •• Ectopic pregnancy Coste J, et al. Am J Pub Health 1991;81(2):199-201. Hyland A, et al. Tob Control 2015;24(4):328-35. Roelands J, et al. J Women’s Health 2009;18(6): 867-72. •• Impaired placental vascularization Ortigosa S, et al. Reprod Toxicol 2012;34(1): 73-9. •• Placenta previa Chelmow D, et al. Obstet Gynecol 1996;87(5 Pt 1): 703-6. Handler AS, et al. Am J Obstet Gynecol 1994;170(3): 884-9. •• Polyhydramnios Myhra W, et al. Am J Pub Health 1992;82(2):176-9. •• Spontaneous abortion Hyland A, et al. Tob Control 2015;24(4):328-35. Kline J, et al. N Engl J Med 1977;297(15): 793-6. Fetal Effects •• Birth defects: gastroschisis, oral cleft Little J, et al. Bull World Health Organ 2004; 82(3):213-23. Skarsgard ED, et al. Birth Defects Res A Clin Mol Teratol 2015;103(2):111-8. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress, 2014 26 •• Low Apgar scores Hammoud A, et al. Am J Obstet Gynecol 2005;192(6): 1856-63. •• Low birth weight Ricketts SA, et al. Am J Pub Health 2005;95(11): 1952-7. Simpson WJ. Am J Obstet Gynecol 1957;73(4):808-15. •• Premature birth Mainous A, Hueston W. J Fam Pract 1994;38(3): 262-6. Mei-Dan E, et al. J Perinat Med 2015;43(5):553-8. Simpson WJ. Am J Obstet Gynecol 1957;73(4):808-15. •• Stillbirth Butler NR, et al. Br Med J 1972;2(5806):127-30. Hyland A, et al. Tob Control 2015;24(4):328-35. Salihu HM, et al. Nicotine Tob Res 2008;10(1):159-66. Childhood Health Effects •• Asthma Gilliland FD, et al. Am J Respir Crit Care Med 2001; 163(2):429-36. Hollams E, et al. Am J Respir Crit Care Med 2014; 189(4):401-7. •• Behavioral problems McCrory C, Layte R. J Abnorm Child Psychol 2012; 40(8):1277-88. Naeye RL, Peters EC. Obstet Gynecol 1984;64(5): 601-7. Wakschlag LS, et al. Arch Gen Psychiatry 1997;54(7): 670-6. •• Cognitive impairments Zhou S, et al. Curr Probl Pediatr Adolesc Health Care 2014;44(8):219-41. •• Ear infections Stathis SL, et al. Pediatrics 1999;104(2):e16. •• Fetal malpresentation Talas BB, et al. Taiwan J Obstet Gynecol 2008; 47(4):402-7. •• Nicotine addiction Kandel D, et al. Am J Pub Health 1994;84(9):1407-13. Niaura RS. Am J Addict 2001;10(1):16-29. •• Intrauterine growth restriction Jaddoe VW, et al. Am J Epidemiol 2007;165(10): 1207-15. Miller HC, et al. Am J Obstet Gynecol 1976;125(1): 55-60. Tong VT, et al. MMWR Surveill Summ 2013;62(6): 1-19. •• Overweight and obesity Gorog K, et al. Matern Child Health J 2011;15(7): 985-92. AJN ▼ June 2017 ▼ Vol. 117, No. 6 •• Sudden infant death syndrome DiFranza JR, Lew RA. J Fam Pract 1995;40(4):385-94. Tong VT, et al. MMWR Surveill Summ 2013;62(6):1-19. ajnonline.com USPHS guideline, especially in vulnerable subpopulations, are needed.15, 17 Motivation to quit involves both internal and external forces that unite in a desire for behavior change. Curry and colleagues defined the intrinsic factors as health concerns and self-control and the extrinsic factors as immediate reinforcement and social influence.24 Present study objectives. The objectives of the present study were twofold: to increase our understanding of the experiences of pregnant smokers, including motivation to quit; and to increase our understanding of providers’ experiences with perinatal smoking cessation programs in order to gain insights that will help providers best deliver the stopsmoking message. METHODS Design and setting. A qualitative descriptive design was used, and data were gathered through focus groups. This methodology is often employed instead of surveys when exploring sensitive issues because focus groups offer opportunities to observe interactions among participants and allow for gathering and analyzing information that is embedded within complex societal contexts.25, 26 This study was conducted with pregnant women and their providers in two rural counties in upper New York State; the health care providers also serve rural northern Pennsylvania. These counties are part of New York’s Southern Tier region, the northern edge of Appalachia, where the prevalence of tobacco use is high, as it is in other rural areas.27 All pregnant women in both counties receive prenatal care at one of 10 private offices that accept both public and private insurance. They give birth at one of three hospitals that provide labor, delivery (a range of 325 to 1,400 births per year), and postpartum services. (See Table 1 for demographic data on the study settings.) Approval for the study was obtained from Binghamton University’s Human Subjects Review Committee and from the institutional review boards of the participating offices and hospital systems. Sample and procedure. Active enrollees in the Medicaid Obstetrical and Maternal Services (MOMS) program who were self-reported smokers and at least 16 weeks pregnant were invited to participate in focus groups. Initial contact was made by the MOMS’ coordinators via e-mailed written invitation or telephone call (or both). Similarly, all nurse and physician providers in both outpatient and inpatient settings were invited to participate in focus groups. At least one coordinator or contact person was identified in each facility; that person contacted prospective participants via written invitation, with face-to-face follow-up. Focus groups for providers and those for pregnant women were conducted at different times and locations. Each group met just once for 90 minutes. All groups were held as dinner meetings, either in private ajn@wolterskluwer.com Table 1. Demographic Profile of Study Settings County 1 County 2 96,874 88,015 70.9 223.2 $41,519 $40,891 96.1% 1.6% 1.1% 1.1% 90.7% 6.3% 2.1% 1.1% 15% 16% Total population Persons per square mile Median annual household income Race/ethnicity White Black Hispanic Asian Percentage below poverty level Note: percentages may not sum to 100% because of rounding. rooms in restaurants (pregnant women) or in conference rooms (providers). All participants gave both written and verbal consent before being enrolled in a focus group. Demographic data were collected before the start of the sessions. Each group had two moderators: one who facilitated discussion using “open listening,” and another who observed nonverbal communication and the general tone and mood of the group and made field notes.28, 29 To ensure reliability and consistency, the principal investigator (one of us, GRB) was the primary moderator for all but one of the focus groups (she chose not to facilitate the one provider group held in her hometown so as not to bias discussion). An incentive of $25 plus dinner was provided. All group discussions were audiotaped with participants’ consent. The discussion with the pregnant smokers was aimed at addressing the study’s first objective and was facilitated by use of a semistructured guide. We asked: 1. What are your impressions of the stop-smoking message you are receiving (or received) from the nurses or physicians when you are (or were) pregnant? (This question referred to both present and past pregnancies.) 2. Did anything stand out? 3. How would you like the nurses or physicians to deal with the subject of smoking? Can you give us an example? 4. Is there anything else you could tell us that would help us improve how we approach this issue? Similarly, the discussion with the providers was aimed at addressing the study’s second objective and was facilitated by use of a semistructured guide. We asked: 1. What are your impressions of smoking cessation efforts targeted to your patients? 2. Does anything stand out as working really well? 3. Does anything stand out as not working well? Can you give us an example? AJN ▼ June 2017 ▼ Vol. 117, No. 6 27 4. I s there anything else you could tell us that would help you in approaching patients about this issue? The moderators used these guides in order to achieve thematic consistency from group to group and to be able to address all the issues that are part of this research. They used reflective listening, silence, and clarification follow-up questions (such as “Can you tell me more about that?”) and statements (such as “I hear you saying . . .”). Additional probing questions were not used because we didn’t want to disturb the flow of the conversation; at the same time, participants were reminded to stay on topic. The moderators were educated on the purpose of the research and trained in focus group facilitation before the study was conducted. Data analysis. The focus group discussions were transcribed verbatim. They were then read and coded independently by each of six reviewers (including GRB and RC) who also listened to the audiotapes of the focus group sessions. The reviewers noted the repetition of words and phrases, which were bracketed for further review and analysis in the interest of identifying key themes that would emerge from such an analysis. When themes were identified, they were confirmed by the six reviewers using a Delphi consensus process. Table 2. Demographic Profile of Focus Group Participants: Providers (N = 45) Variable No. of Providers (%) Sex Female Male 42 (93.3) 3 (6.7) Age, years 20–30 31–40 41–50 51–60 61–70 No answer 4 (8.9) 3 (6.7) 13 (28.9) 21 (46.7) 2 (4.4) 2 (4.4) Race/ethnicity White Asian 42 (93.3) 3 (6.7) Provider role RN MD LPN NP PA MA Nurse manager 32 (71.1) 5 (11.1) 4 (8.9) 1 (2.2) 1 (2.2) 1 (2.2) 1 (2.2) MA = medical assistant; PA = physician assistant. Note: percentages may not sum to 100% because of rounding. 28 AJN ▼ June 2017 ▼ Vol. 117, No. 6 RESULTS There was a total of 66 participants: 45 health care providers and 21 pregnant smokers. The providers were predominantly white (93%) and female (93%), and a majority were RNs (71%). Their work environments were almost equally divided between outpatient and inpatient settings. (See Table 2 for the providers’ demographic data.) All the pregnant women were white, reflecting the rural demographic; 100% were Medicaid insured. The mean age was 24 years. Of the 21 women, 62% were either single (n = 8) or living with a partner (n = 5); the remaining 38% were married (n = 8). (See Table 3 for …
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Assignment: Healthy Information Technology
Assignment: Healthy Information Technology
Assignment: Healthy Information Technology
Assignment: Healthy Information Technology
Assignment: Healthy Information Technology
Assignment: Healthy Information Technology
Assignment: Healthy Information Technology
Assignment: Healthy Information Technology
Assignment: Healthy Information Technology
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