Qualitative systematic review: barriers and facilitators to smoking cessation experienced by women in pregnancy and following childbirth

Aim To explore barriers and facilitators to smoking cessation experienced by women during pregnancy and postpartum by undertaking a synthesis of qualitative studies. Background The majority of pregnant women are aware that smoking in pregnancy compromises maternal and infant health. Despite this knowledge, quit rates among pregnant women remain low, particularly among women in disadvantaged circumstances; disadvantage also increases the chances of living with a partner who smokes and returning to smoking after birth. A deeper understanding of what hinders and what helps pregnant smokers to quit and remain ex-smokers postpartum is needed. Design A synthesis of qualitative research using meta-ethnography. Data sources Five electronic databases (January 1990–May 2013) were searched comprehensively, updating and extending the search for an earlier review to identify qualitative research related to the review's aims. Review methods Following appraisal, 38 studies reported in 42 papers were included and synthesized following the principles of meta-ethnography. Over 1100 pregnant women were represented, the majority drawn from disadvantaged groups. Results Four factors were identified that acted both as barriers and facilitators to women's ability to quit smoking in pregnancy and postpartum: psychological well-being, relationships with significant others, changing connections with her baby through and after pregnancy; appraisal of the risk of smoking. Conclusion The synthesis indicates that barriers and facilitators are not fixed and mutually exclusive categories; instead, they are factors with a latent capacity to help or hinder smoking cessation. For disadvantaged smokers, these factors are more often experienced as barriers than facilitators to quitting

The barriers and facilitators to smoking cessation experienced by women’s partners during pregnancy and the post-partum period: a systematic review of qualitative research

Background Smoking in pregnancy can cause substantial harm and, while many women quit, others continue to smoke throughout pregnancy. The role of partners is an important but relatively under-researched factor in relation to women's smoking in pregnancy; partner's smoking status and attitudes to smoking cessation are important influences in a pregnant women's attempt to quit. Further understanding of how partners perceive the barriers and facilitators to smoking cessation in pregnancy is needed, particularly from qualitative studies where participants describe these issues in their own words. Methods A synthesis of qualitative research of partners' views of smoking in pregnancy and post-partum was conducted using meta-ethnography. Searches were undertaken from 1990 to January 2014 using terms for partner/household, pregnancy, post-partum, smoking, qualitative in seven electronic databases. The review was reported in accordance with the ‘Enhancing transparency in reporting the synthesis of qualitative research' (ENTREQ) statement. Results Nine studies reported in 14 papers were included, detailing the experience of 158 partners; the majority were interviewed during the post-partum period. Partners were all male, with a single exception. Socioeconomic measures indicated that most participants were socially disadvantaged. The synthesis identified recurring smoking-related perceptions and experiences that hindered (barriers) and encouraged (facilitators) partners to consider quitting during the woman's pregnancy and into the post-partum period. These were represented in five lines of argument relating to: smoking being an integral part of everyday life; becoming and being a father; the couple's relationship; perceptions of the risks of smoking; and their harm reduction and quitting strategies. Conclusions The cluster of identified barriers and facilitators to quitting offers pointers for policy and practice. The workplace emerges as an important space for and influence on partners' smoking habits, suggesting alternative cessation intervention locations for future parents. Conversely, health and community settings are seen to offer little support to fathers. Interventions centred on valued personal traits, like will-power and autonomy, may have particular salience. The review points, too, to the potential for health information that directly addresses perceived weaknesses in official advice, for example, around causal mechanisms and effects and around contrary evidence of healthy babies born to smokers. Systematic review registration PROSPERO 2013: CRD4201300417

Health professionals' perceptions of the barriers and facilitators to providing smoking cessation advice to women in pregnancy and during the post-partum period : a systematic review of qualitative research

Background: Reducing smoking in pregnancy is a policy priority in many countries and as a result there has been a rise in the development of services to help pregnant women to quit. A wide range of professionals are involved in providing these services, with midwives playing a particularly pivotal role. Understanding professionals' experiences of providing smoking cessation support in pregnancy can help to inform the design of interventions as well as to improve routine care. Methods: A synthesis of qualitative research of health professionals' perceptions of the barriers and facilitators to providing smoking cessation advice to women in pregnancy and the post-partum period was conducted using meta-ethnography. Searches were undertaken from 1990 to January 2015 using terms for maternity health professionals and smoking cessation advisors, pregnancy, post-partum, smoking, and qualitative in seven electronic databases. The review was reported in accordance with the 'Enhancing transparency in reporting the synthesis of qualitative research' (ENTREQ) statement. Results: Eight studies reported in nine papers were included, reporting on the views of 190 health professionals/ key informants, including 85 midwives and health visitors. The synthesis identified that both the professional role of participants and the organisational context in which they worked could act as either barriers or facilitators to an individual's ability to provide smoking cessation support to pregnant or post-partum women. Underpinning these factors was an acknowledgment that the association between maternal smoking and social disadvantage was a considerable barrier to addressing and supporting smoking cessation Conclusions: The review identifies a role for professional education, both pre-qualification and in continuing professional development that will enable individuals to provide smoking cessation support to pregnant women. Key to the success of this education is recognising the centrality of the professional-client/patient relationship in any interaction. The review also highlights a widespread professional perception of the barriers associated with helping women give up smoking in pregnancy, particularly for those in disadvantaged circumstances. Improving the quality and accessibility of evidence on effective healthcare interventions, including evidence on 'what works' to support smoking cessation in disadvantaged groups, should therefore be a priority

Skill mix in nursing: a selective review of the literature

Skill mix emerged as a prominent issue in nursing at a time when a new environment, imbued with management values, was forged within the NHS. The issues surrounding skill mix are often highly contentious and, not surprisingly, various interest groups either welcome or reject attempts to examine the different combinations of staff, qualified and unqualified, experienced and inexperienced, in relation to costs, outcomes and quality of nursing care. Despite the strong passions aroused by the debate, other factors, most notably demographic changes and the possible shortage of nurses, new demands on health care services and the call for more cost-effective use of resources, have kept skill mix foremost on the policy agenda. This review covers manpower planning, an area where considerable efforts have been made to determine the number but rarely the mix of nurses required to provide the necessary care for patients. In addition, previous work on staff turnover, and the possibility of substituting less qualified for more qualified staff, are examined in relation to cost containment, recruitment and demography, and the creation of a new single level of nurse. These factors, along with the introduction of health care assistants, will have an important influence on the future shape and structure of nursing and, of course, the composition of the skills available. The issues associated with skill mix in nursing are complex and often highly political. As a result, great care is required when determining the combination of scarce, expensive skills which provide good quality patient care at least cost.nursing, skill

Determinants of hospital death in haematological cancers : findings from a qualitative study

Objectives Current UK health policy promotes enabling people to die in a place they choose, which for most is home. Despite this, patients with haematological malignancies (leukaemias, lymphomas and myeloma) are more likely to die in hospital than those with other cancers, and this is often considered a reflection of poor quality end-of-life care. This study aimed to explore the experiences of clinicians and relatives to determine why hospital deaths predominate in these diseases. Methods The study was set within the Haematological Malignancy Research Network (HMRN—www.hmrn.org), an ongoing population-based cohort that provides infrastructure for evidence-based research. Qualitative interviews were conducted with clinical staff in haematology, palliative care and general practice (n=45) and relatives of deceased HMRN patients (n=10). Data were analysed for thematic content and coding and classification was inductive. Interpretation involved seeking meaning, salience and connections within the data. Results Five themes were identified relating to: the characteristics and trajectory of haematological cancers, a mismatch between the expectations and reality of home death, preference for hospital death, barriers to home/hospice death and suggested changes to practice to support non-hospital death, when preferred. Conclusions Hospital deaths were largely determined by the characteristics of haematological malignancies, which included uncertain trajectories, indistinct transitions and difficulties predicting prognosis and identifying if or when to withdraw treatment. Advance planning (where possible) and better communication between primary and secondary care may facilitate non-hospital death

Experiences of living with chronic myeloid leukaemia and adhering to tyrosine kinase inhibitors: A thematic synthesis of qualitative studies

Purpose: To investigate the experiences of adults living with chronic myeloid leukaemia and treated with tyrosine kinase inhibitors, with particular reference to factors influencing adherence. Methods: A thematic synthesis of all published qualitative studies examining adults with chronic myeloid leukaemia, receiving tyrosine kinase inhibitors. Eligible publications were identified by searching five electronic databases using defined criteria. The synthesis involved complete coding of extracted data and inductive theme development. Results: Nine studies were included and three overarching themes defined. Overarching themes were: 1) Disease impacts whole life; 2) Disease management strategies; and 3) Valued aspects of care. Side-effects often required physical and psychological adaptation. Patients developed individual decision-making processes to promote adherence and manage side effects. Unintentional non-adherence occurred due to forgetfulness and system failures. Intentional omission also occurred, which together with side effects, was unlikely to be reported to healthcare professionals (HCPs). HCP reassurance about missed doses could reinforce non-adherence. Information needs varied over time and between individuals. Knowledge among patients about treatment was often lacking and could lead to misunderstandings. Patients valued psychological support from HCPs and suggested an individualised approach, facilitating discussion of symptoms, adherence and their perspectives about living with chronic myeloid leukaemia, would improve care. Conclusions: Patients with chronic myeloid leukaemia experienced significant side-effects from treatment and changes to their psychological and physical well-being. They developed their own strategies to manage their disease and treatment. This should be recognised in interventions to improve education, support and the delivery of care that is compassionate and adequately resourced

Information preferences of patients with chronic blood cancer:a qualitative investigation

BACKGROUND: Haematological malignancies (blood cancers) often follow chronic trajectories that can span many months or years. Management of these diseases typically involves periods of 'Watch & Wait', whereby patients are monitored by the hospital and only treated at progression, if or when this occurs, which might be never or on multiple occasions. Such remitting-relapsing pathways are unpredictable and can cause anxiety and distress. This study aimed to generate evidence about information preferences, with a view to underpinning future patient-facing resources; potentially mitigating psycho-social difficulties and promoting effective shared decision-making. METHODS: A qualitative study was conducted, set within a UK population-based cohort of patients with haematological malignancies. Sampling was purposive, based on age (initially around the median age of diagnosis) and disease subtype (chronic lymphocytic leukaemia, follicular lymphoma, marginal zone lymphoma and myeloma); and in-depth interviews took place with 35 patients (10 with relatives). Analysis drew on qualitative description and thematic content analysis and included critical reading and annotation of transcripts, identification of common and rare phenomena, generation of codes and coding of material, and theme development. RESULTS: Patients discussed their preferences and experiences at length and rich data were generated from diagnosis onwards, across diagnostic subtypes. The overarching theme identified was 'Variations in preferences' with needs seen to differ from person to person; as well as changing over time for individuals. Five sub-themes were identified: 1) To know or not to know? 2) Needs are dynamic; 3) The polarising issue of prognosis; 4) Preferred sources; and 5) Differences in content, depth and presentation. CONCLUSIONS: Varied, dynamic information preferences indicate that resources should be developed in a way that provides maximum choice, enabling patients to select relevant material at different time-points on their trajectory. The development of blood cancer subtype-specific "real-world clinical scenarios" could improve patient experiences and inform shared decision-making

Palliative care specialists' perceptions concerning referral of haematology patients to their services : findings from a qualitative study

Background: Haematological malignancies (leukaemias, lymphomas and myeloma) are complex cancers that are relatively common, affect all ages and have divergent outcomes. Although the symptom burden of these diseases is comparable to other cancers, patients do not access specialist palliative care (SPC) services as often as those with other cancers. To determine the reasons for this, we asked SPC practitioners about their perspectives regarding the barriers and facilitators influencing haematology patient referrals. Methods: We conducted a qualitative study, set within the United Kingdom’s (UK’s) Haematological Malignancy Research Network (HMRN: www.hmrn.org), a population-based cohort in the North of England. In-depth, semistructured interviews were conducted with 20 SPC doctors and nurses working in hospital, community and hospice settings between 2012 and 2014. Interviews were digitally audio-recorded, transcribed and analysed for thematic content using the ‘Framework’ method. Results: Study participants identified a range of barriers and facilitators influencing the referral of patients with haematological malignancies to SPC services. Barriers included: the characteristics and pathways of haematological malignancies; the close patient/haematology team relationship; lack of role clarity; late end of life discussions and SPC referrals; policy issues; and organisational issues. The main facilitators identified were: establishment of interdisciplinary working patterns (co-working) and enhanced understanding of roles; timely discussions with patients and early SPC referral; access to information platforms able to support information sharing; and use of indicators to ‘flag’ patients’ needs for SPC. Collaboration between haematology and SPC was perceived as beneficial and desirable, and was said to be increasing over time. Conclusions: This is the first UK study to explore SPC practitioners’ perceptions concerning haematology patient referrals. Numerous factors were found to influence the likelihood of referral, some of which related to the organisation and delivery of SPC services, so were amenable to change, and others relating to the complex and unique characteristics and pathways of haematological cancers. Further research is needed to assess the extent to which palliative care is provided by haematology doctors and nurses and other generalists and ways in which clinical uncertainty could be used as a trigger, rather than a barrier, to referral. Keywords: Cancer, Leukaemia, Lymphoma, Myeloma, Haematology, Specialist palliative care, End of life, Hospice, Qualitativ

Barriers and facilitators to smoking cessation in pregnancy and postpartum : the healthcare professionals

Objectives: Healthcare professionals and the healthcare environment play a central role in protecting pregnant and postpartum women and their infants from smoking-related harms. This study aimed to better understand the health professional’s perspective on how interactions between women, healthcare professionals and the environment influence how smoking is managed. Design: Semi-structured interviews and focus groups. Methods: Data were from 48 healthcare staff involved in antenatal or postpartum care at two UK sites, including midwives, obstetricians, health visitors, GPs, pharmacists, service commissioners and Stop Smoking Service (SSS) advisors and managers. Thematic analysis was guided by a Social-Ecological Framework (SEF). Results: Themes were divided across three SEF levels and represented factors connected to the management of smoking in the healthcare context and the beliefs and behaviour of pregnant or postpartum smokers. Organisational level: service reconfigurations, 'last resort' nicotine replacement therapy prescribing policies, and non-mandatory training were largely negative factors. There were mixed views on opt-out referral pathways and positive views on carbon monoxide monitoring. Inter-personal level: protection of client-professional relationships often inhibited frank discussions about smoking, and weak inter-service relationships affected SSS referral motivation and quality. Individual level: professionals felt community midwives had primary responsibility for managing smoking, though midwives felt under-skilled doing this. Midwives’ perceived priority for addressing smoking was influenced by the demands from unrelated organisational initiatives. Conclusions: Opportunities to improve clinical support for pregnant smokers exist at organisational, inter-service and healthcare professional levels. Interactions between levels reflect the importance of simultaneously addressing different level-specific barriers to smoking cessation in pregnancy

Systematic review of the evidence on orthotic devices for the management of knee instability related to neuromuscular and central nervous system disorders

Objectives To assess the effectiveness of orthotic devices for the management of instability of the knee in adults with a neuromuscular disorder or central nervous system disorder. Design A systematic review of primary studies. Setting Community. Participants Adults with a neuromuscular disorder or central nervous system disorder and impaired walking ability due to instability of the knee. Interventions Orthoses with the clinical aim of controlling knee instability, for example, knee-ankle-foot orthoses, ankle-foot orthoses and knee orthoses or mixed design with no restrictions in design or material. Primary and secondary outcome measures Conditionspecific or generic patient-reported outcome measures assessing function, disability, independence, activities of daily living, quality of life or psychosocial outcomes; pain; walking ability; functional assessments; biomechanical analysis; adverse effects; usage; patient satisfaction and the acceptability of a device; and resource utilisation data. Results Twenty-one studies including 478 patients were included. Orthotic devices were evaluated in patients with postpolio syndrome, poststroke syndrome, inclusion body myositis and spinal cord injury. The review included 2 randomised controlled trials (RCTs), 3 non-randomised controlled studies and 16 case series. Most were small, single-centre studies with only 6 of 21 following patients for 1 year or longer. They met between one and five of nine quality criteria and reported methods and results poorly. They mainly assessed outcomes related to gait analysis and energy consumption with limited use of standardised, validated, patient-reported outcome measures. There was an absence of evidence on outcomes of direct importance to patients such as reduction in pain and falls. Conclusions There is a need for high-quality research, particularly RCTs, of orthotic devices for knee instability related to neuromuscular and central nervous system conditions. This research should address outcomes important to patients. There may also be value in developing a national registr