The concept of public health involves national and local health initiatives, health education and the creation of social and physical environments to protect and promote population health (Dawson and Verweij, 2015). Health promotion is an integral part of the midwife's role, not only for the woman, but for her family and the wider community (International Confederation of Midwives, 2011; Nursing and Midwifery Council (NMC), 2015). Despite widely accepted health risks and available support, the use of tobacco products remains a health issue in the UK, and smoking cessation is a key health promotion topic for midwives. The experience of promoting smoking cessation in a woman's booking appointment triggered the author to examine the challenges of encouraging a health behaviour change. The woman and her partner were both smokers, and the author's experience is used in the form of a case study to demonstrate the barriers to success encountered by health professionals. Communication methods are discussed, and Ajzen's theory of planned behaviour (Ajzen, 1991) is used to explore the woman's personal attitude, subjective norms and perceived external barriers, before the woman's likelihood to change is determined. Verbal consent from the woman and her partner was gained, and identifying features of the case have been anonymised in compliance with midwives' professional responsibility to maintain confidentiality (NMC, 2015).
The theory of planned behaviour
Lifestyle behaviours such as smoking are acknowledged to be multifactorial, and can be impacted by several influences, including personal attitudes and external pressures (Upton and Thirlaway, 2014). The theory of planned behaviour was developed by Azjen (1991) as a conceptual model of health belief and change. It offers users a systematic consideration of influencers, including personal attitudes towards the behaviour, subjective norms formed by normative beliefs (the opinion of population groups around the individual), and personal control beliefs based on self-efficacy. These can be evaluated to predict and explain behaviours and offer guidance for interventions that may increase the likelihood of behaviour change (Salleh and Laxman, 2015). The Theory of planned behaviour also demonstrates that perceived external barriers (such as peer-pressure) can override other influencers and directly affect likelihood of behaviour (Ajzen, 1991).
Smoking in pregnancy
Smoking in pregnancy remains a leading cause of preventable perinatal morbidity and mortality and is an important area of health promotion for midwives on an individual, community and population level (Department of Health, 2013; Department of Health and Public Health England, 2013; Hertfordshire Health and Wellbeing Board, 2016). For the 2015-2016 period, 10.6% of mothers in England were recorded as smokers at the time of delivery (Lifestyles Statistics Team, 2016). The rate of smoking in pregnancy has fallen over recent years, demonstrating that local and national approaches to smoking cessation are having a positive effect. It should be noted, however, that data on smoking at time of delivery can be inaccurate or incomplete, due to varying data collection quality between Trusts, or factors such as midwives failing to accurately record smoking status (Action on Smoking and Health, 2013).
Pregnancy is an optimal opportunity to promote smoking cessation; Edvardsson et al (2011) stated that perceived risks to an offspring's wellbeing can drive healthy behaviour changes in parents during pregnancy. Despite this, many midwives find conversations surrounding smoking cessation difficult, due to their fear of damaging the important midwife-woman relationship. Flemming et al (2016) identifies this concern and suggest approaching smoking cessation in a non-judgemental way to protect the developing midwife-woman relationship. The National Institute for Health and Care Excellence (NICE) (2006) recommends that midwives and other health professionals use brief intervention based methods when discussing smoking cessation. An example of this is the use of Very Brief Advice (VBA), which is recommended by Public Health England in collaboration with the National Centre for Smoking Cessation and Training (NCSCT) as an effective communication tool for midwives (NCSCT, 2014; McEwan, 2016). VBA has three main elements:
VBA is described by McEwan et al (2012) as advantageous to smoking cessation discussions as it takes up little time and avoids directly challenging participants. The value of even a brief health promotion conversation should not be underestimated; a health conversation lasting 3 minutes or less increases the chance of smoking cessation by up to 3% (Stead et al, 2013).
Starting the conversation
As part of an antenatal clinic placement, the author conducted the booking of a 26-year-old primigravida under the supervision of her mentor (a registered midwife). The woman verbally consented to the author conducting the appointment and reflecting on the experience to develop her learning. The woman was attending her booking appointment with her partner; this was her first contact with a health professional regarding her pregnancy. In accordance with NICE (2016) antenatal care recommendations and the VBA pathway (McEwan, 2016), the author engaged the woman in a conversation regarding lifestyle behaviours, including smoking status. At the time of the appointment, both the woman and her partner were smokers. In line with Ajzen's (1991) theory of planned behaviour, the author sought to identify with woman's personal attitude towards smoking cessation. The woman said that she was considering stopping as she was aware it had a negative impact on her pregnancy, but as she was concerned that the process would be difficult, she had not yet tried to stop.
In this initial conversation, two clear outcome attitudes towards smoking cessation were voiced by the woman. She recognised that there would be positive outcomes for the health of her pregnancy, but also that that there would be resultant stress for her during the process of stopping. Outcome attitudes such as these are formed by an individual's belief that a behaviour will lead to certain results (Munafó and Albery, 2008). Outcome attitudes do not have to be true but are important factors in a woman's personal motivation to change behaviour (Montaño and Kasprzyk, 2008). A personal attitude is influenced not only by outcome attitudes themselves, but also by how worthwhile those outcomes are considered to be (Munafó and Albery, 2008). The woman's opinion that stopping smoking would be difficult appeared to devalue her personal attitude, demonstrated by the fact she had not yet altered her behaviour. Given the woman's reservations, the author could have enquired further into the woman's feelings surrounding smoking cessation. This would have represented a move away from the VBA format, as McEwan et al (2012) suggests further enquiry should be saved for a dedicated stop smoking consultation. However, listening with empathy and allowing the woman to explore her attitudes further may have provided greater insight into the factors affecting the woman's personal attitude, such as external barriers (Efraimsson et al, 2012).
Key communication principles
During the conversation, the author used her awareness of the SOLER principles (Box 1) for effective communication (Egan, 2010) to direct her physical approach to the woman. Open, relaxed body language and eye-contact were used, conveying a non-threatening, focussed appearance. Marcinowicz et al (2010) demonstrated that non-verbal actions by health professionals are key contributors to patient satisfaction, compliance and clinical outcome. Stickley (2011) suggested an updated version of SOLER in the SURETY principles (Box 1), which highlight the importance of professionals using their own intuition to guide their physical approach to communication. The importance of intuitive communication in midwifery practice was similarly recognised by Geraghty and Lauva (2015), who wrote that intuition relies on the midwife's receptive communication skills and the ability to respond to cues based on the situation alongside previous experiences.
| SOLER | SURETY |
|---|---|
| Sit straight |
Sit at an angle |
Listening is well recognised as an important part of effective communication for health professionals (Chief Nursing Officer and Chief Nursing Adviser, 2012; NMC, 2015). Hoppe (2011) highlighted the great impact of poor listening, and recommended the practice of active listening to create meaningful conversation. The author demonstrated active listening skills; reflecting on what the woman had said, and responding appropriately, demonstrating understanding and empathy. At this stage, the woman appeared to be relaxed, focused and engaging well with the author, suggesting effective communication was taking place. England and Raynor (2010) emphasised the value of effective communication, stating it helps build strong connections between midwife and woman.
The value of carbon monoxide measurement
The author offered the woman a carbon monoxide (CO) measurement, which is acknowledged to be a fast, cost-effective, and non-invasive method of confirming smoking status or identifying non-disclosed smokers (Ripoll et al, 2012). Choi et al (2013) found that women had an increased motivation to stop smoking when carbon monoxide monitoring was used alongside a brief intervention; however it should be noted there was no difference in rates of smoking cessation compared to brief intervention alone. Despite relatively high sensitivity and specificity in identifying smokers, the potential for misidentification remains; Edwins (2013) urged midwives consider alternative environmental causes of elevated carbon monoxide and warned that carbon monoxide measurement should not replace the trusting bond between midwife and woman. The midwife mentoring the author was reluctant to perform a carbon monoxide measurement, citing a lack of time, and informed the woman that it could be performed at her next antenatal appointment. The impact of institutional pressures, including time constraints, on midwives' perceived ability to fulfil their role as health promoters is well recognised (Flemming et al, 2016; Lee et al, 2012). However, given the speed of carbon monoxide measurement (McEwan, 2016) and its potential value in motivating women to stop smoking, this represents a missed opportunity in the care provided to the woman.
Shaping normative beliefs
With the aim of emphasising the importance of smoking cessation, the author described key risks associated with smoking in pregnancy, explaining that cigarettes contain harmful substances that affect the developing fetus and placenta (Mund et al, 2013). The author also explained how smoking results in increased circulating carbon monoxide levels, reducing oxygen transfer to placental-fetal circulation (Banderali et al, 2015). The woman was informed that smoking was associated with increased risk of miscarriage and stillbirth, placental abruption, preterm delivery, intrauterine growth restriction with resultant low birthweight, and future health problems for offspring (including respiratory conditions, childhood obesity and behavioural disorders). The author also described the association between smoking and environmental smoke, and sudden infant death syndrome (SIDS) (Hayashi et al, 2011; Ko et al, 2014; Banderali et al, 2015).
The author based her approach on previous appointments she had witnessed, and on her professional responsibility to ensure women are aware of risks (NMC, 2015). Through this interaction, the author aimed to shape the woman's normative beliefs: that is, the woman's understanding of other populations' opinions of her behaviour (Ajzen, 1991). It was assumed that, when faced with the medical risks of smoking, the woman's motivation to comply would be high, resulting in a subjective norm in favour of smoking cessation. However, as the theory of planned behaviour demonstrates, knowledge is not necessarily sufficient to change a behaviour; other factors including external barriers can significantly affect this (Ajzen, 1991).
The approach of the author appeared to damage the developing midwife-woman bond and this may have negatively influenced the woman's self-efficacy. This damage was indicated through a visual change in the woman's body language, suggesting she was no longer engaged in the conversation. Sale and Neale (2014) remind health professionals that the key to effective communication is self-awareness and the approach taken will directly impact how patients respond. Flemming et al (2016) identified that midwives often avoid providing women with information regarding the harm of smoking through fear of damaging the midwife-woman relationship. Furthermore, a lack of training and resultant low self-confidence is widely cited as a barrier to midwives delivering appropriate, effective health advice (De Wilde et al, 2015; Flemming et al, 2016). However, this barrier can be easily overcome; Brose et al (2012) demonstrated that health professionals' self-efficacy and knowledge levels increased significantly following completion of online training modules on VBA.
Creating a positive image
As normative beliefs are shaped by those around the individual, the author's actions could directly affect the formation of these beliefs (Ajzen, 1991). By focusing the conversation on creating a positive image in the woman's mind, as McEwan (2016) suggests, the author may have been more successful at shaping the woman's normative beliefs than she had been when using the risk-based approach. The creation of a positive image can act as motivation to women, which, as Lawrence et al (2016) recognised, can contribute to successful behaviour changes. By emphasising that changing behaviour could significantly reduce the risks to pregnancy, and motivating the woman to engage with local Stop Smoking Services, the author could have increased the woman's self-efficacy. Aveyard et al (2012) found a significantly increased rate of smoking cessation when smokers were offered advice and support in comparison to being advised to stop on medical grounds alone.
Aids to discussion
To ensure compliance with professional responsibilities of ensuring informed choice (NMC, 2015), the author could have used available literature and provided the woman with a leaflet identifying the key risks to pregnancy that smoking posed, such as the ‘Love Your Bump’ campaign information leaflet for parents (Hertfordshire County Council, 2015). Written literature is a commonly used communication aid in health promotion; Piddennavar and Krishnappa (2015) concluded that the use of written information increased retention of the provided information, resulting in increased patient satisfaction compared to oral communications alone. The woman was offered a referral to the local Stop Smoking Services in accordance to the VBA approach (McEwan, 2016), although no supplementary information was provided. Given the chance of success increases when women engage with available psychosocial support (Chamberlain et al, 2013), the author should have emphasised the services available. Ajzen (1991) highlights that a key factor in predicting behaviour change is an individual's self-efficacy.
The woman's self-efficacy may have increased had she been aware pregnant women and their families are prioritised for support by local Stop Smoking Services. This support increases accessibility by facilitating various communication methods, using a range of settings such as home visits, and providing free access to behavioural support and nicotine replacement therapies (NRTs) (NCSCT, 2014).
Involving the partner
The woman appeared reluctant to be referred to Stop Smoking Services; she reiterated she felt it would be difficult to cope without cigarettes, demonstrating low self-efficacy. Furthermore, she added that, as her partner was also a smoker, she would struggle to stop. The theory of planned behaviour demonstrates how awareness of a need to change behaviour will not necessarily result in that behaviour change; perceived external barriers can influence or even override intentions to change (Ajzen, 1991). The woman identified that her partner posed a strong influence on her ability to stop smoking, overriding her personal attitude and the normative beliefs expressed by wider society. Hemsing et al (2012) described how partner smoking status was shown to directly impact smoking cessation efforts in pregnant women: women whose partners smoke find it more difficult to stop smoking, and are more likely to relapse. Furthermore, a supportive partner who also aims to stop smoking can increase a woman's ability to change her smoking habit (Hemsing et al, 2012). This highlights the importance of midwives providing holistic care through engagement with partners and family in the promotion of smoking cessation. If successful, the likelihood of women successfully stopping smoking is increased (Hemsing et al, 2012).
The author described the risks of environmental smoke inhalation to pregnancy and infant mortality to the woman's partner. The author's risk-based approach evoked a similar negative response in the partner as it had previously with the woman, further suggesting an alternative approach—focused on motivation—may have been more beneficial. Flemming et al (2015) identified that focussing on the partner's motivation to be supportive and good father facilitated smoking cessation efforts, although this study was limited in its small sample size. The partner was offered the opportunity to be referred to Stop Smoking Services, but he was resistant to referral and defended his smoking habit, stating he needed cigarettes to cope with a demanding, stressful job. The partner's reasoning that smoking was an integral part of everyday life, and part of his social and work environment, mirrors one of five common narratives that Flemming et al (2015) identified in partners who continue to smoke.
The ongoing process of health promotion
The conversation ended with neither the woman nor her partner accepting referral to Stop Smoking Services. By considering the smoking cessation conversation in relation to the theory of planned behaviour (Ajzen, 1991), it is clear that perceived external barriers and low self-efficacy outweighed the woman's personal attitude and normative beliefs, resulting in no positive behaviour change. The author documented the discussion in the woman's notes, in accordance with professional standards (NMC, 2015). In line with the NHS Future Forum's ethos of ensuring every contact counts (NHS Future Forum, 2012), the author recorded that smoking cessation should be discussed again at the woman's next antenatal appointment, and carbon monoxide monitoring should be performed. This highlights an understanding by the author that health promotion is an ongoing process, and although unsuccessful in this conversation, there is further opportunity for the woman's behaviour to change. Due to the scheduling of regular antenatal appointments, midwives are ideally placed to make every contact count.
Midwifery 2020 (Chief Nursing Officers, 2010) identifies that midwives have a unique opportunity to contribute to health promotion by working with women throughout their pregnancy. Public Health England (2014) identified smoking cessation and prevention as one of seven health promotion priorities for England. Although the measured outcome of this aim is identifying the numbers of 15-year olds who smoke, it is recognised that midwives can impact the health of not only the mother, but also those around her and the wider population beyond the perinatal period (Chief Nursing Officers, 2010). Furthermore, with studies demonstrating children in a smoking household are up to three times more likely to become smokers themselves, the impact of smoking cessation in pregnancy can be far reaching (Leonardi-Bee et al, 2011).
Conclusion
Smoking cessation is a key health promotion issue for midwives, due to the significant health implications smoking in pregnancy poses to mother and infant. The retrospective use of the theory of planned behaviour has allowed the author to take a holistic view of a woman's booking appointment and identify areas of strength in her skills and knowledge. However, the experience also highlights several points where more could have been done to achieve a positive outcome. Barriers to the conversation identified included institutional pressures but mainly centred on ineffective communication skills. The use of non-judgmental, empathetic communication skills and the adoption of the recommended brief intervention approach to smoking cessation can overcome these barriers. The author has since completed the NCSCT's online training in VBA, increasing her knowledge and confidence in engaging women and their partners in smoking cessation conversations. The identification of the varying influences that can impact smoking cessation, including institutional pressures, will guide future practice, and can be related to other critical incidents in health promotion. The important role that midwives play in health promotion on an individual, community and national level should not be underestimated—instead, it should be considered an integral part of midwifery practice.
‘By emphasising that changing behaviour could significantly reduce the risks to pregnancy, and by motivating the woman to engage with local Stop Smoking Services, the author could have increased the woman's self-efficacy‘