Pregnant women's receipt of comprehensive guideline recommended antenatal care for smoking.

INTRODUCTION: Antenatal clinical guidelines recommend antenatal care providers routinely assess smoking status for all pregnant women at the first antenatal visit and, for women who are current smokers, provide cessation support at the first and all subsequent visits. This study aimed to assess women's receipt of comprehensive guideline recommended care for smoking during pregnancy and the maternal and service characteristics associated with such care. METHODS: A telephone survey was conducted with women who were recently pregnant and received antenatal care from public maternity services in one Australian local health district. RESULTS: Of the 514 participants, 9% were smokers when they found out they were pregnant. Of these, 47% continued smoking until giving birth. Almost all participants (96%) were asked about their smoking status at their first antenatal visit. Among pregnant smokers, 76% were asked about their smoking at subsequent visits, 73% were advised to quit, 62% were provided with information or advice to assist quitting, 24% were offered Nicotine Replacement Therapy (NRT) and 38% were offered a referral to Quitline. A third of maternal smokers reported receiving all elements of guideline recommended care. No associations were found between maternal and service characteristics and receipt of care for smoking. CONCLUSIONS: Guideline recommended routine assessment and care for smoking in pregnancy may be less than optimal, particularly for smoking cessation interventions with strong evidence of effectiveness - NRT and quit lines. Identification of barriers and implementation of strategies to increase the offer and uptake of these services by women is required. IMPLICATIONS: This study is the first to examine pregnant women's reported receipt of comprehensive guideline recommended care for maternal smoking. The findings indicate that a significant proportion of pregnant women attending public maternity services are not receiving comprehensive care and that many are not being offered evidence based interventions to assist them to quit. Barriers to comprehensive care delivery need to be identified and addressed if the potential for smoking interventions delivered in this setting to impact smoking rates in pregnancy is to be realised.

Antenatal care practices for gestational weight gain: a cross sectional survey of antenatal care providers reported provision and barriers to providing recommended care.

BACKGROUND: Implementation of recommended gestational weight gain (GWG) care by antenatal care providers is poor. It is unclear whether practice implementation and barriers differ between antenatal care provider profession or experience. This study aimed to assesses the provision of and barriers to guideline care for GWG and examine associations with professional discipline and years of experience. METHODS: A cross sectional survey was conducted with antenatal care providers working in three public maternity services in a regional city in Australia. Data were collected on the provision of and barriers (informed by the Theoretical Domains Framework) to recommended GWG care. Data were summarised using descriptive statistics. Associations between health profession characteristics (professional discipline and years providing antenatal care) and GWG care practices and barrier outcomes were assessed using multivariate logistic regression. RESULTS: 117 antenatal care providers completed the survey (75% participation rate). One quarter (25%) reported that they routinely provided recommended GWG assessment at the first antenatal visit, and 9% at subsequent visits. Only 7% routinely provided recommended advice on GWG, healthy eating and physical activity. Professional discipline or years of experience were not associated with higher odds of GWG practices. Skills, belief about capabilities, belief about consequences and environmental context and resources were barriers to providing care. Medical professionals had higher odds of agreeing that they have been adequately trained to address GWG (OR = 9.14, 95%CI:3.10-26.90) and feel competent in having sensitive conversations with pregnant women about GWG (OR = 8.60, 95%CI:2.29-32.28) than midwives. Midwives had higher odds of agreeing that there are services they can refer pregnant women to for further support (OR = 2.80, 95%CI:1.13-6.91). CONCLUSIONS: The provision of antenatal care for GWG was low, inconsistently provided and did not differ by professional discipline or years of experience. Antenatal care providers report numerous barriers including skills, belief about capabilities, belief about consequences, and environmental context and resources. Barriers to GWG care provision differed by professional discipline, but not years of providing care. The findings demonstrate that the type and prioritisation of practice-change implementation strategies may need to be tailored to address the differential barriers faced by professional groups.

Antenatal care addressing gestational weight gain (GWG): a cross sectional study of pregnant women's reported receipt and acceptability of recommended GWG care and associated characteristics.

BACKGROUND: The Australian Clinical Practice Guidelines for Pregnancy Care recommend that during the first and subsequent antenatal visits all pregnant women are weighed; advised of recommended gestational weight gain (GWG), dietary intake and physical activity; and offered referrals for additional support if needed. The extent to which these recommendations are implemented and women's acceptability of recommended care is unknown. This study examines women's reported receipt and acceptability of guideline care for GWG, and characteristics associated with receipt of such care and its acceptability. METHODS: From September 2018 to February 2019 a telephone survey was undertaken with women who had recently had a baby and received antenatal care from five public maternity services within a health district in Australia. Women self-reported their demographic characteristics, and receipt and acceptability of recommended GWG care. Receipt and acceptability of such care, and their association with the characteristics of women and the maternity service they attended, were examined using descriptive statistics and multivariable logistic regression analyses. RESULTS: Of 514 women, 13.1% (95%CI:10.3-16.5) reported that they received an assessment of weight at both their first and a subsequent antenatal visit, and less than one third (30.0%; 95%CI:26.0-33.9) received advice on their recommended GWG range, dietary intake and physical activity. Just 6.6% (95%CI:4.8-9.1) of women reported receiving all assessment and advice components of recommended antenatal care, and 9.9% (95%CI:7.6-12.8) of women reported being referred for extra support. Women who were younger (OR = 1.13;95%CI:1.05-1.21), identifying as Aboriginal and Torres Strait Islander (OR = 24.54;95%CI:4.98-120.94), had a higher pre-pregnancy BMI (OR = 1.13;95%CI:1.05-1.21), were experiencing their first pregnancy (OR = 3.36;95%CI:1.27-8.86), and lived in a least disadvantaged area (compared to mid-disadvantaged area (OR = 18.5;95%CI:2.6-130.5) and most disadvantaged area (OR = 13.1;95%CI:2.09-82.4)) were more likely to receive recommended assessment and advice. Most Aboriginal (92%) and non-Aboriginal (93%) women agreed that recommended GWG care is acceptable. CONCLUSION: Most women perceive antenatal care for GWG as recommended by the Clinical Practice Guidelines as acceptable, but did not receive it. When provided, such care is not delivered consistently to all women regardless of their characteristics or those of the maternity service they attend. There is a need for service-wide practice change to increase routine GWG care in pregnancy for all women.

Clustering of smoking, alcohol consumption and weight gain in pregnancy: prevalence, care preferences and associated factors.

BACKGROUND: Smoking, alcohol consumption and weight gain outside recommendations during pregnancy are preventable health risk factors associated with poorer health outcomes for mother and infant. Clustering of these risk factors further increases the risk and severity of outcomes. Limited research has explored the characteristics of pregnant women that are associated with clustering of these risks and women's preferences for receiving support. This paper aimed to determine: (i) the prevalence of clustered preventable risk factors; (ii) associations between maternal characteristics and presence of clustered risk factors; and (iii) women's preferences for receiving care for clustered risk factors. METHODS: A cross-sectional survey was undertaken with women who had recently given birth in public maternity services in New South Wales, Australia. Descriptive statistics were used to assess prevalence of clustered risk factors and care preferences. Associations between the presence of clustered risk factors and maternal characteristics were assessed using multiple regression analyses. RESULTS: Of the 514 women who completed the survey, 52% reported one preventable health risk factor and 10% and 2% reported two or three. For women with two or more risk factors, the most common combination was alcohol consumption and gestational weight gain outside of recommendations (50%, n = 30). One characteristic had an association with the presence of clustered risk factors. Most women (77%, n = 46) with clustered risk factors indicated they wanted support for these health risks. Preferences for support addressing some or all risk factors, and whether the support was sequential or simultaneous, were not associated with particular risk factor combinations. CONCLUSIONS: Around one in eight women reported clustered preventable risk factors during pregnancy, most of whom would like support to address these risks. There was only one association between maternal characteristics and clustered risk factors. This suggests a need for antenatal care that is women-centred and caters for a diverse profile of clustered risks and varied preferences for care.

Acceptance of smoking cessation support and quitting behaviours of women attending Aboriginal Maternal and Infant Health Services for antenatal care.

BACKGROUND: Acceptance of smoking cessation support during antenatal care and associated quitting behaviours of pregnant Aboriginal women or women having an Aboriginal baby has not been investigated. This study aimed to determine, among pregnant women who smoke and attended AMIHS for their antenatal care: 1. The acceptance of smoking cessation support, factors associated with acceptance and barriers to acceptance; 2. The prevalence of quitting behaviours and factors associated with quitting behaviours. METHODS: A cross-sectional telephone survey of women who attended 11 AMIHSs for their antenatal care during a 12 month period in the Hunter New England Local Health District of New South Wales. RESULTS: One hundred women contacted consented to complete the survey (76%). Of those offered cessation support, 68% accepted NRT, 56% accepted follow-up support and 35% accepted a Quitline referral. Participants accepting NRT had greater odds of quitting smoking at least twice during the antenatal period [OR = 6.90 (CI: 1.59-29.7)] and those reporting using NRT for greater than eight weeks had six times the odds of quitting smoking for one day or more [OR = 6.07 (CI: 1.14-32.4)]. CONCLUSIONS: Aboriginal women or women having an Aboriginal baby who smoke make multiple attempts to quit during pregnancy and most women accept smoking cessation support when offered by their antenatal care providers. Acceptance of care and quitting success may be improved with increased focus on culturally appropriate care and enhanced training of antenatal care providers to increase skills in treating nicotine addiction and supporting women to use NRT as recommended by treatment guidelines.

Real-time video counselling for smoking cessation.

BACKGROUND: Real-time video communication software such as Skype and FaceTime transmits live video and audio over the Internet, allowing counsellors to provide support to help people quit smoking. There are more than four billion Internet users worldwide, and Internet users can download free video communication software, rendering a video counselling approach both feasible and scalable for helping people to quit smoking. OBJECTIVES: To assess the effectiveness of real-time video counselling delivered individually or to a group in increasing smoking cessation, quit attempts, intervention adherence, satisfaction and therapeutic alliance, and to provide an economic evaluation regarding real-time video counselling. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Specialised Register, CENTRAL, MEDLINE, PubMed, PsycINFO and Embase to identify eligible studies on 13 August 2019. We searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov to identify ongoing trials registered by 13 August 2019. We checked the reference lists of included articles and contacted smoking cessation researchers for any additional studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs), randomised trials, cluster RCTs or cluster randomised trials of real-time video counselling for current tobacco smokers from any setting that measured smoking cessation at least six months following baseline. The real-time video counselling intervention could be compared with a no intervention control group or another smoking cessation intervention, or both. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data from included trials, assessed the risk of bias and rated the certainty of the evidence using the GRADE approach. We performed a random-effects meta-analysis for the primary outcome of smoking cessation, using the most stringent measure of smoking cessation measured at the longest follow-up. Analysis was based on the intention-to-treat principle. We considered participants with missing data at follow-up for the primary outcome of smoking cessation to be smokers. MAIN RESULTS: We included two randomised trials with 615 participants. Both studies delivered real-time video counselling for smoking cessation individually, compared with telephone counselling. We judged one study at unclear risk of bias and one study at high risk of bias. There was no statistically significant treatment effect for smoking cessation (using the strictest definition and longest follow-up) across the two included studies when real-time video counselling was compared to telephone counselling (risk ratio (RR) 2.15, 95% confidence interval (CI) 0.38 to 12.04; 2 studies, 608 participants; I2 = 66%). We judged the overall certainty of the evidence for smoking cessation as very low due to methodological limitations, imprecision in the effect estimate reflected by the wide 95% CIs and inconsistency of cessation rates. There were no significant differences between real-time video counselling and telephone counselling reported for number of quit attempts among people who continued to smoke (mean difference (MD) 0.50, 95% CI -0.60 to 1.60; 1 study, 499 participants), mean number of counselling sessions completed (MD -0.20, 95% CI -0.45 to 0.05; 1 study, 566 participants), completion of all sessions (RR 1.13, 95% CI 0.71 to 1.79; 1 study, 43 participants) or therapeutic alliance (MD 1.13, 95% CI -0.24 to 2.50; 1 study, 398 participants). Participants in the video counselling arm were more likely than their telephone counselling counterparts to recommend the programme to a friend or family member (RR 1.06, 95% CI 1.01 to 1.11; 1 study, 398 participants); however, there were no between-group differences on satisfaction score (MD 0.70, 95% CI -1.16 to 2.56; 1 study, 29 participants). AUTHORS' CONCLUSIONS: There is very little evidence about the effectiveness of real-time video counselling for smoking cessation. The existing research does not suggest a difference between video counselling and telephone counselling for assisting people to quit smoking. However, given the very low GRADE rating due to methodological limitations in the design, imprecision of the effect estimate and inconsistency of cessation rates, the smoking cessation results should be interpreted cautiously. High-quality randomised trials comparing real-time video counselling to telephone counselling are needed to increase the confidence of the effect estimate. Furthermore, there is currently no evidence comparing real-time video counselling to a control group. Such research is needed to determine whether video counselling increases smoking cessation.

Supporting Aboriginal Women to Quit Smoking: Antenatal and Postnatal Care Providers' Confidence, Attitudes, and Practices.

INTRODUCTION: Tobacco use during pregnancy is substantially higher among Aboriginal women compared to non-Aboriginal women in Australia. However, no studies have investigated the amount or type of smoking cessation care that staff from Aboriginal antenatal and postnatal services provide to clients who smoke or staff confidence to do so. This study examined Aboriginal antenatal and postnatal staff confidence, perceived role and delivery of smoking cessation care to Aboriginal women and characteristics associated with provision of such care. METHODS: Staff from 11 Aboriginal Maternal and Infant Health Services and eight Aboriginal Child and Family Health services in the Hunter New England Local Health District in Australia completed a cross-sectional self-reported survey (n = 67, response rate = 97.1%). RESULTS: Most staff reported they assessed clients' smoking status most or all of the time (92.2%). However, only a minority reported they offered a quitline referral (42.2%), provided follow-up support (28.6%) or provided nicotine replacement therapy (4.7%) to most or all clients who smoked. Few staff felt confident in motivating clients to quit smoking (19.7%) and advising clients about using nicotine replacement therapy (15.6%). Staff confident with talking to clients about how smoking affected their health had significantly higher odds of offering a quitline referral [OR = 4.9 (1.7-14.5)] and quitting assistance [OR = 3.9 (1.3-11.6)] to clients who smoke. CONCLUSIONS: Antenatal and postnatal staff delivery of smoking cessation care to pregnant Aboriginal women or mothers with young Aboriginal children could be improved. Programs that support Aboriginal antenatal and postnatal providers to deliver smoking cessation care to clients are needed. IMPLICATIONS: Aboriginal antenatal and postnatal service staff have multiple opportunities to assist Aboriginal women to quit smoking during pregnancy and postpartum. However, staff confidence and practices of offering various forms of smoking cessation support to pregnant Aboriginal women is unexplored. This is the first study to examine the amount and type of smoking cessation support Aboriginal antenatal and postnatal service staff provide to Aboriginal women, staff confidence and their perceived role in delivering smoking cessation care. This information is valuable for developing strategies that assist antenatal and postnatal staff to improve their delivery of smoking cessation care to Aboriginal women.

A Cluster Randomised Controlled Trial of a Brief Child Health Nurse Intervention to Reduce Infant Secondhand Smoke Exposure.

Background Exposure to secondhand smoke (SHS) is a significant contributor to ill health in children. A study was undertaken to determine the effectiveness of two brief multi-strategic child health nurse delivered interventions in: decreasing the prevalence of infants exposed to SHS; decreasing the prevalence of smoking amongst parent/carers of infants and increasing the prevalence of household smoking bans. Methods This study was a 3 arm, cluster randomised controlled trial. Clusters were 39 community based well child health clinics in one local area health service. Clinics were stratified according to annual number of client appointments and then randomly assigned in a 1:1:1 ratio, (Intervention 1: Intervention 2: Control), with 13 clinics in each cluster. Parents/carers of infants in the intervention groups received a brief multi-strategic intervention from child health nurses during clinic consultations. Treatment condition 1 included computer delivered risk assessment and feedback and nurse brief advice. Treatment condition 2 included all elements of Treatment condition 1 with the addition of biochemical feedback of infant SHS exposure. Results When compared to the Control group at 12 months, no significant differences in the prevalence of infant exposure to SHS were detected from baseline to follow-up for Treatment condition 1 (OR 1.16, 95 % CI 0.73-1.85, p = 0.53) or Treatment condition 2 (OR 1.30, 95 % CI 0.88-1.92, p = 0.19) Similarly, no significant differences were detected in the proportion of parent/carers who reported that they were smokers (T1:OR 0.95, 95 % CI 0.78-1.15, p = 0.58 and T2:OR 0.97, 95 % CI 0.80-1.18, p = 0.77), or in the proportion of households reported to have a complete smoking ban (T1:OR 1.21, 95 % CI 0.89-1.64, p = 0.23 and T2:OR 1.06, 95 % CI 0.79-1.43, p = 0.68). Conclusions Further research is required to identify effective interventions that can be consistently provided by child health nurses if the potential of such settings to contribute to reductions in child SHS exposure is to be realised.

Effect of implementation strategies on the routine provision of antenatal care addressing smoking in pregnancy: study protocol for a non-randomised stepped-wedge cluster controlled trial.

INTRODUCTION: Globally, guideline-recommended antenatal care for smoking cessation is not routinely delivered by antenatal care providers. Implementation strategies have been shown to improve the delivery of clinical practices across a variety of clinical services but there is an absence of evidence in applying such strategies to support improvements to antenatal care for smoking cessation in pregnancy. This study aims to determine the effectiveness and cost effectiveness of implementation strategies in increasing the routine provision of recommended antenatal care for smoking cessation in public maternity services. METHODS AND ANALYSIS: A non-randomised stepped-wedge cluster-controlled trial will be conducted in maternity services across three health sectors in New South Wales, Australia. Implementation strategies including guidelines and procedures, reminders and prompts, leadership support, champions, training and monitoring and feedback will be delivered sequentially to each sector over 4 months. Primary outcome measures will be the proportion of: (1) pregnant women who report receiving a carbon monoxide breath test; (2) smokers or recent quitters who report receiving quit/relapse advice; and (3) smokers who report offer of help to quit smoking (Quitline referral or nicotine replacement therapy). Outcomes will be measured via cross-sectional telephone surveys with a random sample of women who attend antenatal appointments each week. Economic analyses will be undertaken to assess the cost effectiveness of the implementation intervention. Process measures including acceptability, adoption, fidelity and reach will be reported. ETHICS AND DISSEMINATION: Ethics approval was obtained through the Hunter New England Human Research Ethics Committee (16/11/16/4.07; 16/10/19/5.15) and the Aboriginal Health and Medical Research Council (1236/16). Trial findings will be disseminated to health policy-makers and health services to inform best practice processes for effective guideline implementation. Findings will also be disseminated at scientific conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry-ACTRN12622001010785.

E-cigarette use in pregnancy in Australia: A cross-sectional survey of public antenatal clinic attendees.

INTRODUCTION: E-cigarette use has rapidly increased amongst young people in Australia, however the prevalence of use amongst pregnant people is not known. The aim of this study was to examine the prevalence of e-cigarette use and dual use of e-cigarettes and tobacco cigarettes, characteristics associated with use and reasons for use amongst a sample of pregnant Australian people attending public antenatal clinics. METHODS: A cross-sectional survey was conducted with 4024 pregnant people attending antenatal appointments, between July 2021 and December 2022, in one local health district in New South Wales, Australia. Main outcome measures were current use of e-cigarettes, dual use with tobacco cigarettes, participant characteristics associated with use and reasons for use. RESULTS: 1.24% of pregnant people used e-cigarettes, 34% of these were dual smokers. Being a current smoker (OR 39.49; 95% CI 9.99-156.21) or ex-smoker (OR 29.86; 95% CI 8.75-101.95) were associated with e-cigarette use. Quitting smoking was the most reported reason for use (52%). DISCUSSION AND CONCLUSIONS: This study is the first to report on the prevalence of e-cigarette use amongst pregnant people in Australia. We found that a small proportion of pregnant people use e-cigarettes and that many are dual users or ex-smokers. E-cigarette use and rates of dual use in pregnancy in Australia appear lower than internationally, however they are similarly being used as a smoking-cessation aid by many. As regulatory environments relating to e-cigarette access change in Australia, large-scale studies are required to continue to monitor e-cigarette use and dual use in pregnancy.

Breastfeeding practices and associations with pregnancy, maternal and infant characteristics in Australia: a cross-sectional study.

BACKGROUND: Exclusive breastfeeding to six months of age is a major global public health priority. Several characteristics are known to be associated with early cessation of breastfeeding, however, limited evidence exists regarding whether women's reported reasons for cessation are associated with maternal, pregnancy and infant characteristics. The aims of this study were to: i) describe women's reported intention to breastfeed and their subsequent breastfeeding practices; ii) describe women's reported reasons for breastfeeding cessation prior to the infant being five months of age; and iii) examine associations between these factors and maternal, pregnancy and infant characteristics. METHODS: Telephone and online surveys were conducted between October 2019 and April 2020 with 536 women who had given birth in the previous eight to 21 weeks at four public maternity services in Australia. RESULTS: The majority of women intended to (94%), and did, initiate (95%) breastfeeding. At the time the survey was conducted, 57% of women were exclusively breastfeeding. Women who: had less than University level education, had a pre-pregnancy BMI in the overweight or obese category, and who smoked tobacco at the time of the survey had lower odds of exclusively breastfeeding. The most common self-reported reasons for breastfeeding cessation were breastfeeding challenges (47%) and low milk supply (40%). Women aged 26-35 years and 36 + years had greater odds of reporting breastfeeding cessation due to low milk supply (OR = 2.92, 95% CI: 1.11, 7.66; OR = 5.57, 95% CI: 1.70, 18.29) compared to women aged 18-25 years. While women who had completed a TAFE certificate or diploma had lower odds of reporting this as a reason for breastfeeding cessation (OR = 0.28; 95% CI: 0.11, 0.73) compared to women who had University level education. There were no other significant associations found between characteristics and reasons for ceasing breastfeeding. CONCLUSIONS: The most common reasons for breastfeeding cessation may be modifiable through the provision of breastfeeding support in the early postpartum period, with such support being tailored to women's age and level of education. Such support should aim to increase women's self-efficacy in breastfeeding, and be provided from the antenatal period and throughout the first six months postpartum.

The effectiveness of implementation strategies in improving preconception and antenatal preventive care: a systematic review.

BACKGROUND: Clinical guideline recommendations for addressing modifiable risk factors are not routinely implemented into preconception and antenatal care. This review assessed the effectiveness of implementation strategies in improving health professional provision of preconception and antenatal care addressing tobacco smoking, weight management and alcohol consumption. METHODS: A systematic review of randomised and non-randomised studies with a parallel comparison group was conducted. Eligible studies used implementation strategy/ies targeted at health professionals to improve at least one element of preconception and/or antenatal care (smoking: ask, advise, assess, assist, arrange; weight/alcohol: assess, advise, refer) compared to usual practice/control or alternative strategies. Eligible studies were identified via CENTRAL, MEDLINE, EMBASE, Maternity and Infant Care, CINAHL and other sources. Random-effects meta-analyses were conducted where appropriate, with other findings summarised using the direction of effect. The certainty of the pooled evidence was assessed using the GRADE approach. RESULTS: Fourteen studies were included in the review. Thirteen were in the antenatal period and 12 tested multiple implementation strategies (median: three). Meta-analyses of RCTs found that implementation strategies compared to usual practice/control probably increase asking (OR: 2.52; 95% CI: 1.13, 5.59; 3 studies; moderate-certainty evidence) and advising (OR: 4.32; 95% CI: 3.06, 6.11; 4 studies; moderate-certainty evidence) about smoking and assessing weight gain (OR: 57.56; 95% CI: 41.78, 79.29; 2 studies; moderate-certainty evidence), and may increase assessing (OR: 2.55; 95% CI: 0.24, 27.06; 2 studies; low-certainty evidence), assisting (OR: 6.34; 95% CI: 1.51, 26.63; 3 studies; low-certainty evidence) and arranging support (OR: 3.55; 95% CI: 0.50, 25.34; 2 studies; low-certainty evidence) for smoking. The true effect of implementation strategies in increasing advice about weight gain (OR: 3.37; 95% CI: 2.34, 4.84; 2 non-randomised studies; very low-certainty evidence) and alcohol consumption (OR: 10.36; 95% CI: 2.37, 41.20; 2 non-randomised studies; very low-certainty evidence) is uncertain due to the quality of evidence to date. CONCLUSIONS: Review findings provide some evidence to support the effectiveness of implementation strategies in improving health professional delivery of antenatal care addressing smoking and weight management. Rigorous research is needed to build certainty in the evidence for improving alcohol and weight gain advice, and in preconception care. TRIAL REGISTRATION: PROSPERO-CRD42019131691.

A randomised controlled trial of proactive telephone counselling on cold-called smokers' cessation rates.

OBJECTIVES: Active telephone recruitment ('cold calling') can enroll almost 45 times more smokers to cessation services than media. However, the effectiveness of proactive telephone counselling with cold-called smokers from the broader community is unknown. This study examined whether proactive telephone counselling improved abstinence, quit attempts and reduced cigarette consumption among cold-called smokers. METHODS: From 48,014 randomly selected electronic telephone directory numbers, 3008 eligible smokers were identified and 1562 (51.9%) smokers recruited into the randomised controlled trial. Of these, 769 smokers were randomly allocated to proactive telephone counselling and 793 to the control (ie, mailed self-help) conditions. Six counselling calls were offered to intervention smokers willing to quit within a month and four to those not ready to quit. The 4-month, 7-month and 13-month follow-up interviews were completed by 1369 (87.6%), 1278 (81.8%) and 1245 (79.9%) participants, respectively. RESULTS: Proactive telephone counselling participants were significantly more likely than controls to achieve 7-day point prevalence abstinence at 4 months (13.8% vs 9.6%, p=0.005) and 7 months (14.3% vs 11.0%, p=0.02) but not at 13 months. There was a significant impact of telephone counselling on prolonged abstinence at 4 months (3.4% vs 1.8%, p=0.02) and at 7 months (2.2% vs 0.9%, p=0.02). At 4 months post recruitment, telephone counselling participants were significantly more likely than controls to have made a quit attempt (48.6% vs 42.9%, p=0.01) and reduced cigarette consumption (16.9% vs 9.0%, p=0.0002). CONCLUSIONS: Proactive telephone counselling initially increased abstinence and quitting behaviours among cold-called smokers. Given its superior reach, quitlines should consider active telephone recruitment, provided relapse can be reduced. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry; ACTRN012606000221550.

A school-based resilience intervention to decrease tobacco, alcohol and marijuana use in high school students.

BACKGROUND: Despite schools theoretically being an ideal setting for accessing adolescents and preventing initiation of substance use, there is limited evidence of effective interventions in this setting. Resilience theory provides one approach to achieving such an outcome through improving adolescent mental well-being and resilience. A study was undertaken to examine the potential effectiveness of such an intervention approach in improving adolescent resilience and protective factor scores; and reducing the prevalence of adolescent tobacco, alcohol and marijuana use in three high schools. METHODS: A non-controlled before and after study was undertaken. Data regarding student resilience and protective factors, and measures of tobacco, alcohol and marijuana use were collected from grade 7 to 10 students at baseline (n = 1449) and one year following a three year intervention (n = 1205). RESULTS: Significantly higher resilience and protective factors scores, and significantly lower prevalence of substance use were evident at follow up. CONCLUSIONS: The results suggest that the intervention has the potential to increase resilience and protective factors, and to decrease the use of tobacco, alcohol and marijuana by adolescents. Further more rigorous research is required to confirm this potential.

A cross-sectional survey of the prevalence of environmental tobacco smoke preventive care provision by child health services in Australia.

BACKGROUND: Despite the need for a reduction in levels of childhood exposure to environmental tobacco smoke (ETS) being a recognised public health goal, the delivery of ETS preventive care in child health service settings remains a largely unstudied area. The purpose of this study was to determine the prevalence of ETS preventive care in child health services; differences in the provision of care by type of service; the prevalence of strategies to support such care; and the association between care support strategies and care provision. METHOD: One-hundred and fifty-one (83%) child health service managers within New South Wales, Australia completed a questionnaire in 2002 regarding the: assessment of parental smoking and child ETS exposure; the provision of parental smoking cessation and ETS-exposure reduction advice; and strategies used to support the provision of such care. Child health services were categorised based on their size and case-mix, and a chi-square analysis was performed to compare the prevalence of ETS risk assessment and ETS prevention advice between service types. Logistic regression analysis was used to examine associations between the existence of care support strategies and the provision of ETS risk assessment and ETS exposure prevention advice. RESULTS: A significant proportion of services reported that they did not assess parental smoking status (26%), and reported that they did not assess the ETS exposure (78%) of any child. Forty four percent of services reported that they did not provide smoking cessation advice and 20% reported they did not provide ETS exposure prevention advice. Community based child and family health services reported a greater prevalence of ETS preventive care compared to other hospital based units. Less than half of the services reported having strategies to support the provision of ETS preventive care. The existence of such support strategies was associated with greater odds of care provision. CONCLUSIONS: The existence of major gaps in recommended ETS preventive care provision suggests a need for additional initiatives to increase such care delivery. The low prevalence of strategies that support such care delivery suggests a potential avenue to achieve this outcome.

An implementation intervention to increase the routine provision of antenatal care addressing gestational weight gain: study protocol for a stepped-wedge cluster trial.

BACKGROUND: Weight gain during pregnancy that is outside of recommended levels is associated with a range of adverse outcomes for the mother and child, including gestational diabetes, pre-eclampsia, preterm birth, and obesity. Internationally, 60-80% of pregnant women report gaining weight outside of recommended levels. While guideline recommendations and RCT evidence support the provision of antenatal care that supports healthy gestational weight gain, less than 10% of health professionals routinely weigh pregnant women; discuss weight gain, diet, and physical activity; and provide a referral for additional support. This study aims to determine the effectiveness of an implementation intervention in increasing the provision of recommended gestational weight gain care by maternity services. METHODS: A stepped-wedge controlled trial, with a staggered implementation intervention, will be conducted across maternity services in three health sectors in New South Wales, Australia. The implementation intervention will consist of evidence-based, locally-tailored strategies including guidelines and procedures, reminders and prompts, leadership support, champions, training, and monitoring and feedback. Primary outcome measures will be the proportion of women who report receiving (i) assessment of gestational weight gain; (ii) advice on gestational weight gain, dietary intake, and physical activity; and (iii) offer of referral to a telephone coaching service or local dietetics service. Measurement of outcomes will occur via telephone interviews with a random sample of women who attend antenatal appointments each week. Economic analyses will be undertaken to assess the cost, cost-consequence, cost-effectiveness, and budget impact of the implementation intervention. Receipt of all care elements, acceptance of referral, weight gain during pregnancy, diet quality, and physical activity will be measured as secondary outcomes. Process measures including acceptability, adoption, fidelity, and reach will be reported. DISCUSSION: This will be the first controlled trial to evaluate the effectiveness of a implementation intervention in improving antenatal care that addresses gestational weight gain. The findings will inform decision-making by maternity services and policy agencies and, if the intervention is demonstrated to be effective, could be applied at scale to benefit the health of women and children across Australia and internationally. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry, ACTRN12621000054819 . Registered on 22 January 2021.

Are antenatal interventions effective in improving multiple health behaviours among pregnant women? A systematic review protocol.

BACKGROUND: Maternal behaviours in pregnancy associated with adverse pregnancy, birth and health outcomes include tobacco smoking, poor nutrition, alcohol consumption and low physical activity, collectively referred to as the SNAP risk factors. Due to the high prevalence, co-occurrence and possible interactive health effects of such health behaviours in pregnancy, antenatal interventions that support pregnant women to improve multiple SNAP behaviours have a greater potential impact on the health outcomes of women and their children than interventions addressing single behaviours. The objective of this review is to determine the effectiveness of interventions delivered as part of antenatal care that aim to improve multiple SNAP behaviours among pregnant women. METHODS: Seven electronic databases will be searched for potentially eligible studies. Eligible studies will include those where pregnant women are attending antenatal care. Studies that examine the effect of an intervention that addresses multiple SNAP behaviours (≥ 2 behaviours) during pregnancy and are delivered or instigated through antenatal care in a healthcare service will be included. Systematic reviews of randomised controlled trials (RCTs), RCTs, cluster RCTs, stepped-wedge RCTs and non-randomised control trials will be eligible. Studies that include a no-intervention control, wait-list control group, standard/usual care, or another active single behavioural intervention (e.g. addressing one behaviour only) will be considered. Two independent reviewers will conduct study screening, data extraction and risk of bias assessment. Discrepancies will be resolved by consensus or a third reviewer if required. A random effects model will be used to synthesise the results. Alternative synthesis methods will be investigated in instances where a meta-analysis is not appropriate, such as summarising effect estimates, combining P values, vote counting based on direction of effect, or synthesis in narrative form. DISCUSSION: The review will synthesise the evidence on the effect of interventions that address multiple SNAP behaviours in antenatal care and will help researchers, policy-makers and health services to develop and deliver best practice integrated models of antenatal care that have the potential to impact on both the short- and long-term health outcomes for women and their children. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018095315.

Implementation strategies to improve preconception and antenatal care for tobacco smoking, alcohol consumption and weight management: a systematic review protocol.

BACKGROUND: Despite existing best practice care recommendations for addressing tobacco smoking, alcohol consumption and weight management in preconception and antenatal care, such recommendations are often not implemented into routine practice. Effective strategies that target known barriers to implementation are key to reducing this evidence to practice gap. The aim of this review is to synthesise the evidence on the effectiveness of implementation strategies in improving the provision of preconception and antenatal care for these modifiable risk factors. METHODS: Randomised and non-randomised study designs will be eligible for inclusion if they have a parallel control group. We will include studies that either compare an implementation strategy to usual practice or compare two or more strategies. Participants may include any health service providing preconception or antenatal care to women and/or the health professionals working within such a service. The primary outcome will be any measure of the effectiveness of implementation strategies to improve preconception and/or antenatal care for tobacco smoking, alcohol consumption and/or weight management (including care to improve nutrition and/or physical activity). Secondary outcomes will include the effect of the implementation strategy on women's modifiable risk factors, estimates of absolute costs or cost-effectiveness and any reported unintentional consequences. Eligible studies will be identified via searching Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Maternity and Infant Care, CINAHL, ProQuest Dissertations and Theses and other sources (e.g. contacting experts in the field). Study selection, data extraction and risk of bias will be assessed independently by two review authors and differences resolved by a third reviewer. If data permits, we will conduct fixed-effects or random-effects meta-analysis where appropriate. If studies do not report the same outcome or there is significant heterogeneity, results will be summarised narratively. DISCUSSION: This review will identify which implementation strategies are effective in improving the routine provision of preconception and antenatal care for tobacco smoking, alcohol consumption and weight management. Such a review will be of interest to service providers, policy makers and implementation researchers seeking to improve women's modifiable risk factors in preconception and antenatal care settings. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019131691.

Interventions by Health Care Professionals Who Provide Routine Child Health Care to Reduce Tobacco Smoke Exposure in Children: A Review and Meta-analysis.

IMPORTANCE: Reducing child exposure to tobacco smoke is a public health priority. Guidelines recommend that health care professionals in child health settings should address tobacco smoke exposure (TSE) in children. OBJECTIVE: To determine the effectiveness of interventions delivered by health care professionals who provide routine child health care in reducing TSE in children. DATA SOURCES: A secondary analysis of 57 trials included in a 2014 Cochrane review and a subsequent extended search was performed. Controlled trials (published through June 2015) of interventions that focused on reducing child TSE, with no restrictions placed on who delivered the interventions, were identified. Secondary data extraction was performed in August 2015. STUDY SELECTION: Controlled trials of routine child health care delivered by health care professionals (physicians, nurses, medical assistants, health educators, and dieticians) that addressed the outcomes of interest (TSE reduction in children and parental smoking behaviors) were eligible for inclusion in this review and meta-analysis. DATA EXTRACTION AND SYNTHESIS: Study details and quality characteristics were independently extracted by 2 authors. If outcome measures were sufficiently similar, meta-analysis was performed using the random-effects model by DerSimonian and Laird. Otherwise, the results were described narratively. MAIN OUTCOMES AND MEASURES: The primary outcome measure was reduction in child TSE. Secondary outcomes of interest were parental smoking cessation, parental smoking reduction, and maternal postpartum smoking relapse prevention. RESULTS: Sixteen studies met the selection criteria. Narrative analysis of the 6 trials that measured child TSE indicated no intervention effects relative to comparison groups. Similarly, meta-analysis of 9 trials that measured parental smoking cessation demonstrated no overall intervention effect (n = 6399) (risk ratio 1.05; 95% CI, 0.74-1.50; P = .78). Meta-analysis of the 3 trials that measured maternal postpartum smoking relapse prevention demonstrated a significant overall intervention effect (n = 1293) (risk ratio 1.53; 95% CI, 1.10-2.14; P = .01). High levels of study heterogeneity likely resulted from variability in outcome measures, length of follow up, intervention strategies, and unknown intervention fidelity. CONCLUSIONS AND RELEVANCE: Interventions delivered by health care professionals who provide routine child health care may be effective in preventing maternal smoking relapse. Further research is required to improve the effectiveness of such interventions in reducing child TSE and increasing parental smoking cessation. The findings of this meta-analysis have policy and practice implications relating to interventions by routine pediatric health care professionals that aim to reduce child exposure to tobacco smoke.

Increasing the health promotion practices of workplaces in Australia with a proactive telephone-based intervention.

PURPOSE: The aim of this study was to explore the potential effectiveness of a proactive telephone-based intervention in increasing workplace adoption of health promotion initiatives. METHODS: A telephone-based direct marketing strategy was used to contact a sample of Australian workplaces to encourage the adoption of health promotion initiatives. Workplaces were offered free services and resources designed to facilitate adoption of health promotion initiatives. RESULTS: A total of 227 (71%) workplaces provided informed consent to participate in both baseline and 4-year follow-up surveys. Significant increases were evident for seven of the eight health promotion initiatives. DISCUSSION: The findings of this study suggest that a proactive telephone-based intervention has the potential to be effective in increasing the prevalence of health promotion initiatives across a range of health topics in a large population of workplaces. Given the capacity to reach an entire population of workplaces, this approach represents a promising means of achieving the established potential of workplace health promotion.