- Title
- Investigating cessation of smoking during pregnancy in Indigenous Australian women, drivers of relapse and access to services that might help continue cessation.
- Creator
- Rahman, Tabassum
- Relation
- University of Newcastle Research Higher Degree Thesis
- Resource Type
- thesis
- Date
- 2022
- Description
- Research Doctorate - Doctor of Philosophy (PhD)
- Description
- Background: Smoking during pregnancy remains a public health concern for women and their babies. While the global prevalence of smoking in pregnancy is 1.7%, a much higher proportion of Indigenous women in high-income countries with similar histories of European colonisation smoke during pregnancy. In Australia, commercial tobacco was largely introduced among Aboriginal and Torres Strait Islander peoples via colonisation. Tobacco was given to Aboriginal and Torres Strait Islander peoples as payment for labour and rations, leading to ingrained tobacco dependence. When combined with inequity in the social determinants of health, cessation of tobacco smoking becomes even more challenging. While the motivation for giving up smoking during pregnancy is high among Aboriginal and Torres Strait Islander women, abstaining from smoking after making a quit attempt can be difficult. Yet there is limited evidence on pregnant and postpartum Aboriginal and Torres Strait Islander women’s experience during the periods of smoking abstinence and the systemic barriers to effectively support them in achieving long-term smoking abstinence. This PhD research aims to enhance smoking cessation care for pregnant and postpartum Aboriginal and Torres Strait Islander women by informing relevant practice and policies, focusing on maintaining smoking abstinence. Methods: A pragmatic methodological approach was employed. Four studies were conducted using a socioecological model as a theoretical framework. These explored and analysed factors at different levels of the socioecological model, i.e., the system, wider society, community, family/partner, and individual levels, influencing pregnant and postpartum Aboriginal and Torres Strait Islander women’s smoking cessation experiences. Studies were conducted using the following methods: a) a systematic narrative review of the literature to map the barriers to and enablers of smoking cessation among pregnant and postpartum Aboriginal and Torres Strait Islander women (Study 1, Chapter 3); b) a qualitative study with 12 Aboriginal women from an urban setting in New South Wales, Australia, to explore their experiences of maintaining smoking abstinence and strategies they applied to avoid relapse (Study 2, Chapter 4); c) a mixed-methods analysis of a cross-sectional, online study with 103 Aboriginal and Torres Strait Islander women to further explore smoking cessation experiences during pregnancy and postpartum periods (Study 3, Chapter 5); and d) a qualitative study with 26 key informants providing smoking cessation care to pregnant and postpartum Aboriginal and Torres Strait Islander women or working in the field of tobacco control, to explore systemic barriers to provision of smoking cessation care including relapse prevention (Study 4, Chapter 6). Results: The systematic narrative review (Study 1, Chapter 3) found that colonial legacy in policies following colonisation such as the introduction of commercial tobacco, dispossession of land, and disparities in opportunities for education, employment and housing perpetuated inequity and socioeconomic disadvantages. Furthermore, the experience of racism contributed to stressful life circumstances often caused by the above determinants of health. Such stresses may intensify during pregnancy for Aboriginal and Torres Strait Islander women influenced by physiological and emotional changes and level of social support. Quitting smoking during pregnancy and maintaining abstinence was found to be difficult for Aboriginal and Torres Strait Islander women in community contexts where social cues for smoking were common, and smoking was a shared activity, often used for stress release. Smoking cessation care provision often lacked cultural relevance and was not resourced with adequate training for health professionals and informed by Aboriginal and Torres Strait Islander-specific evidence. Conversely, high motivation, being receptive to health professionals’ advice, family and peer support, and self-initiated strategies to give up smoking could enable cessation. The qualitative study with Aboriginal women used multiple coping strategies in combination to remain abstinent before and after having their babies (Study 2, Chapter 4). Those strategies include replacing smoking with a different activity, keeping busy, doing something for self, forward-thinking and eliciting support from close associations who smoke to avoid social cues. A need for more relatable information on how to better manage nicotine craving was highlighted. A preferred way of delivering this information was via women’s groups, with a strong focus on culture. The mixed-methods analysis of the national level online survey data revealed that motivation for quitting in pregnancy was high, with 93% of Aboriginal and Torres Strait Islander women reporting that they made significant changes in their smoking behaviour (Study 3, Chapter 5). Those who used Aboriginal Medical Services for general health care had a 4.54 times higher chance of having a smoke-free pregnancy than those who did not use Aboriginal Medical Services. Geographic location was associated with having a smoke-free pregnancy, with Aboriginal and Torres Strait Islander women living in urban settings having 67% less chance of maintaining abstinence during pregnancy. Women’s smoking cessation experiences varied within and across pregnancies, and multiple attempts to give up smoking during pregnancy were common to achieve complete cessation. The qualitative study with key informants revealed that the systemic barriers smoking cessation care providers faced arose from policies that influence access to resources and approaches to smoking cessation care to address maternal smoking (Study 4, Chapter 6). A lack of funding for individual level smoking cessation care provided at Aboriginal Medical Services and time limitations faced by health professionals offering smoking cessation care to Aboriginal and Torres Strait Islander women were major service level barriers to relapse prevention. Tobacco-related health messages often lacked relevance to long-term abstinence. Consistent, dedicated funding for Aboriginal Medical Services and other services to support individual-level smoking cessation care for Aboriginal and Torres Strait Islander women is needed. Discussion: These findings indicate that a comprehensive multi-level approach to smoking cessation during pregnancy is required. At the system level, this comprehensive approach needs to include policy changes to alleviate the social determinants of health and address stressors and improve smoking cessation care provision with better training for health professionals. The system level findings also highlighted the necessity of consistent funding to continue Aboriginal Medical Service-led, culturally appropriate smoking cessation support for pregnant and postpartum Aboriginal and Torres Strait Islander women. The inclusion of dedicated smoking cessation workers and better health professionals’ training with updated evidence may improve smoking cessation care for pregnant and postpartum Aboriginal and Torres Strait Islander women. Individual level smoking cessation care and community level health promotion activities should engage Aboriginal and Torres Strait Islander families and communities to provide supportive and empowering environments to facilitate women’s success in smoking cessation during pregnancy and maintain abstinence. Clear and consistent messaging to quit smoking during pregnancy and maintain abstinence for long-term should be emphasised by health professionals. Individual level smoking cessation care and community level health promotion initiatives need to emphasise on smoking cessation during pregnancy and maintaining abstinence. At an individual level, there is a need for more support from health professionals and for building self-control. The factors that help them maintain smoking abstinence need to be further explored. Conclusion: Systemic initiatives are urgently needed to address major barriers impacting the smoking cessation workforce’s ability to support pregnant and postpartum Aboriginal and Torres Strait Islander women quitting smoking and maintaining abstinence. Engagement of Aboriginal and Torres Strait Islander communities and families in creating a favourable quitting environment is critical in helping Aboriginal and Torres Strait Islander women to stay smoke-free. Ongoing investment in individual level smoking cessation care is necessary to enable smoking cessation support providers to adequately respond to pregnant and postpartum Aboriginal and Torres Strait Islander women’s needs. Prioritising Aboriginal and Torres Strait Islander-specific evidence on smoking cessation during pregnancy and maintaining abstinence is required. Such policy initiatives can contribute to achieving the Close the Gap target for increasing the proportion of healthy birthweight babies born to Aboriginal and Torres Strait Islander mothers to 91% and reducing the gap in life expectancy within a generation by 2031.
- Subject
- smoking cessation; health behaviour; behavioural change; social determinants of health; Aboriginal and Torres Strait Islander health
- Identifier
- http://hdl.handle.net/1959.13/1508273
- Identifier
- uon:56111
- Rights
- Copyright 2022 Tabassum Rahman
- Language
- eng
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| Thumbnail | File | Description | Size | Format | |||
|---|---|---|---|---|---|---|---|
| View Details Download | ATTACHMENT01 | Thesis | 7 MB | Adobe Acrobat PDF | View Details Download | ||
| View Details Download | ATTACHMENT02 | Abstract | 368 KB | Adobe Acrobat PDF | View Details Download |