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PhD Thesis - Cooke, M

Barriers to the systematic provision of smoking cessation education during pregnancy
Cooke M (1998)

Abstract:
The research literature suggests that clinicians fail to adequately use health education interventions that have been demonstrated to be effective. This thesis examines the use of smoking cessation education (SCE) by clinicians who care for pregnant women. It investigates the clinician, organisational and dissemination variables which impact on the provision of smoking cessation education in antenatal clinics.

Individual behaviour change theory, organisational theory and diffusion theory are used to guide the design and analysis of the research. A series of cross-sectional studies are used to investigate the provision of SCE and the outcomes of dissemination of a tested SCE program. Data are collected from multiple sources and both qualitative and quantitative research methods are used.

Studies 1 and 2 indicated there was a performance gap between the reported SCE practice of clinicians who provide care for pregnant women and the recommended guidelines for SCE practice. The primary modifiable barriers to the provision of SCE by clinicians were: low clinician self-efficacy; inadequate smoking assessment; lack of hospital SCE policy; and inadequate training. To overcome these barriers a SCE program was disseminated to 23 hospital antenatal clinics in NSW. Prior to dissemination the organisational context of the clinics was explored using qualitative methods to determine the potential barriers to dissemination and to recommend strategies to overcome these barriers (study 3).

The remaining studies (4-6) describe the outcomes of program dissemination using two methods of dissemination (intensive and simple). Clinics were randomly allocated to the two dissemination methods. Studies 4 and 5 describe program adoption by clinic managers three months after the initial dissemination. Study 6 investigates the implementation and maintenance of the program by clinicians 18 months after dissemination. The final study also examines the effect of two methods of dissemination on the provision of SCE in antenatal clinics.

Most managers adopted or partially adopted the new SCE program. Adoption scores were associated with the method of dissemination and the manager's perceptions of the program. Dissemination method did not effect the number of SCE interventions provided by clinics, but clinicians in the intensive dissemination group were more likely to use more intensive and effective forms of SCE intervention. Nevertheless, the program was poorly implemented and SCE was not systematically provided in clinics after dissemination. The organisational, individual and dissemination barriers to health education are described.

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