In this study we found that better smoking cessation knowledge, a positive attitude towards providing cessation advice and being employed by a government health service were significantly associated with higher rates of self-reported assessment of smoking status while providing antenatal care to pregnant Aboriginal women. There is some indication that being a non-smoker, and disagreeing with statements expressing concern that women would be pushed away from antenatal care or about having inadequate skills were also associated with higher rates of assessment, but these relationships were not statistically significant at the 5% level.
To our knowledge, this is the first study to specifically explore the knowledge and attitudes regarding smoking among service providers caring for pregnant Aboriginal women in Australia. The study was undertaken in two jurisdictions among antenatal care providers in remote, regional and urban Australian settings. The number of eligible providers was less than anticipated and the consequent small sample may have limited our ability to identify other significant associations. However, the response rate was good and the sample is likely to represent this group of service providers reasonably well.
Consistent with studies among other antenatal care providers [28
], the majority of respondents considered that assessing smoking status of all women was integral to good antenatal care and a professional and service responsibility. The majority also indicated that they do ask all women about their smoking. However, over one fifth reported not always asking all women, indicating a missed opportunity for addressing a major preventable risk factor for adverse birth outcomes. While there may be over-estimation of rates of assessment due to social desirability bias, the positive attitudes expressed by the majority of respondents are an asset with potential to be enhanced by training and skills development.
In general, knowledge of risks associated with smoking was high, particularly in relation to birth outcomes and infant illness, but not for childhood health problems. An earlier study of Australian directors of antenatal clinics identified poor specific knowledge of risks [33
]. Others have reported that providers did not consider smoking a serious risk to infant health [35
]. The uncertainty regarding risks of ongoing problems in childhood indicates gaps in knowledge and lost opportunities for conveying the true burden of antenatal smoking. As provider knowledge of risk is essential for conveying clear messages regarding risk to women, education of providers regarding the specific risks associated with smoking is essential.
Knowledge of smoking cessation was poor and inversely associated with level of assessment. Only half the respondents recognised that complete and sudden cessation was an effective quitting method; three quarters incorrectly indicated that gradual reduction was effective; and one third incorrectly indicated that NRT shouldn't be used in pregnancy despite national guidelines stating that NRT can be used in pregnancy [41
]. Other studies have also identified a preference among antenatal providers for advising reduction rather than complete cessation [33
]. Smoking cessation interventions are poorly covered in nursing curricula [46
] and in training for Aboriginal Health Workers [47
], which may explain the low level of knowledge and that approximately one fifth felt they didn't have the skills to provide advice. Perceived skill level is associated with provision of tobacco interventions [37
], and lack of skills have repeatedly been identified as a barrier to smoking cessation counselling by practitioners [31
]. In our study, both knowledge scores and perceptions of skills were related to level of smoking assessment, suggesting that provision of culturally appropriate, pregnancy-specific training and resources would increase confidence and skills and consequently assessment and management of antenatal smoking.
Although only a small proportion of respondents agreed that giving advice was not worth it, this perception was strongly associated with level of reported assessment, suggesting that pessimism regarding the impact of advice may contribute to non-assessment of smoking status. Pessimism about the effectiveness of interventions has been identified as a barrier to providing cessation counselling in other Australian antenatal settings [37
] and internationally [38
]. The poor knowledge of smoking cessation identified is likely to contribute to low efficacy of any advice provided, further contributing to a perception that advising cessation is futile. Within the context of providing care to women with multiple complex care needs with constrained resources [5
], providers who anticipate low success rates may prioritise other activities which are easier to implement or have greater chance of success.
Provider smoking has been shown to be negatively associated with smoking cessation counselling [48
] and smoking is perceived to be a barrier to providing cessation counselling among Aboriginal Health Workers [6
]. Several studies have suggested assisting AHWs to quit in order to increase their comfort in providing cessation support [55
]. Although only 19 (15%) of the respondents smoked, provision of smoking cessation support to those who do is likely to be beneficial for the individuals, enhance their willingness to provide cessation supports, and give them personal experience in quitting.
One quarter of the respondents indicated concern that providing advice might push women away and this was associated with lower smoking assessment, although this was not significant at the 5% level in the multivariable analysis. In a Western Australian study of smoking during pregnancy, AHWs expressed discomfort about raising smoking as they wished to maintain positive relationships with women [6
]. Similar concerns have been identified in other studies with AHWs, although they report feeling more comfortable discussing smoking with pregnant smokers than with other smokers [39
]. In other antenatal settings, a perception that clients are not interested or do not expect advice, has been identified as a barrier [37
], and midwives have expressed concern about potentially damaging their relationship with women if they address their smoking [28
]. By contrast, women consider provision of smoking cessation advice within antenatal care to be acceptable [26
], and state that it doesn't affect their relationships with their midwives [27
]. However, the manner of providing care is important, and should not be authoritarian [28
]. Greater community and provider understanding of the real risks of smoking and benefits of cessation may increase community support and help providers feel more comfortable addressing smoking.
Limitations to this research should be considered in interpreting the findings. In addition to the small sample size and potential social desirability bias mentioned above, the cross-sectional nature of the survey prevents assessment of causality in the relationship between assessment and the knowledge and attitudinal variables. Factors other than the knowledge and attitudinal variables included in our study may be determining respondents smoking cessation activities, and the reported attitudes may then reflect a rationalisation on the part of respondents to justify their behaviour. Trials of interventions that aim to address knowledge and attitudes would be beneficial in assessing this. A further limitation is that the study did not assess the amount or type of advice that the clinicians provide to women.