Table 1 Barriers to and enablers of the provision of smoking cessation support, TDF domains and COM-B components, potential intervention types and BCTs initially identified
Theme | COM-B TDF domain | Potential intervention types | BCTs |
|---|---|---|---|
Barriers | |||
 Clinician knowledge of the guidelines was poor and many were unaware that the 5As should be delivered at every visit [23, 24]. | Psychological capability Knowledge | Education | Education • 4.1 Instruction on how to perform a behaviour (information on how and when to provide the 5As) • 6.3 Information about other’s approval (explain Ministry of Health policy and guidelines) • 9.1 Credible source (above information provided by credible source) |
 There was some confusion regarding the value of cutting down versus quitting [23]. | Psychological capability Knowledge | Education | Education • 5.1 Information about health consequences (provide information on the risks/benefits of quitting vs cutting down) |
 Many clinicians reported poor knowledge and communication skills related to the Assist component, in particular (i) assisting motivated women with strategies to quit (including use of NRT), (ii) assisting to motivate women to try to quit who are not currently motivated and (iii) arranging follow-up [23, 24]. | Psychological capability Cognitive and interpersonal skills | Training | Training • 4.1 Instruction on how to perform a behaviour (detailed information on how to assist women with strategies including the use of NRT in pregnancy, and how to motivate them) • 6.1 Demonstration of the behaviour (demonstration of how to perform each of the elements of assisting under varying circumstances) • 8.1 Behavioural practice/rehearsal (practice performing the elements of assisting using role play) |
 There were no mechanisms or systems for clinicians to use to monitor/self-monitor if they were following the 5As [23, 24]. | Psychological capability Behavioural regulation | Education Enablement | Education • 2.2 Feedback on the behaviour (provide information on clinic performance providing 5As) Enablement • 1.2 Problem solving • 1.4 Action planning • 2.3 Self-monitoring (encourage midwives to problem solve barriers and solutions to self-monitoring, and make a plan to manage this) |
 Many clinicians thought that the 5As took too long to deliver within the context of a busy antenatal visit [23, 24]. | Physical opportunity Environmental context and resources | Training | Training • 4.1 Instruction on how to perform a behaviour (reiterating 5As designed to be delivered in a short consultation) • 6.1 Demonstration of the behaviour (how to have 5As discussions while doing other clinical duties) • 8.1 Behavioural practice/rehearsal (practice performing the elements of assisting using role play) |
 There were no service-wide systems to identify smokers at subsequent visits and remind clinicians to deliver 5As [23, 24]. | Physical opportunity Environmental context and resources | Environmental restructuring | Environmental restructuring • 7.1 Prompts/cues (options: modify EMR to include flags for smokers (now complete), build in reminders to follow 5As at every antenatal visit and ensure key fields are included for all antenatal visits. If modifying EMR is not possible, develop a linked add-on decision support system; or develop paper-based reminders) • 12.5 Adding objects to the environment (as above for 7.1, and add posters and colourful, prominent lists in the clinic) |
 There was no system to monitor smoking cessation support that women received, for quality assurance purposes [23, 24]. | Physical opportunity Environmental context and resources | Training Environmental restructuring | Environmental restructuring • 12.5 Adding objects to the environment (develop a reporting system for managers to monitor cessation support provided) Training • 4.1 Instruction on how to perform a behaviour (train key leaders in the use of the reporting system) |
 Lack of resources, e.g. printed materials to use with women who smoke were unavailable, out of date or not specific to pregnancy [23, 24]. | Physical opportunity Environmental context and resources | Environmental restructuring | Environmental restructuring • 12.5 Adding objects to the environment (might be printed pamphlets, or links to online resources which can be centrally updated) |
 Lack of leadership for smoking cessation and a lack of champions at all levels including both managers and peers [23, 24]. | Social opportunity Social influences | Enablement | Enablement • 3.1 Social support (unspecified) (buddy identified at training to provide ongoing support) • 12.2 Restructuring the social environment (manager encouraging attendance at training; discussion of 5As in meetings) • 2.2 Feedback on behaviour (develop mechanism to allow the manager to monitor progress on provision of 5As (or some component) and encourage this at team meetings/display in staff room, etc.) |
 Some midwives lacked confidence to deliver the 5As, especially assisting women who were struggling [23, 24]. | Reflective motivation Beliefs about capabilities | Persuasion Incentivisation Enablement | Persuasion • 15.3 Focus on past success and 15.1 verbal persuasion about capability (highlight communication skills midwives have developed in other areas) • 9.1 Credible source (delivered by senior or other respected midwives) Incentivisation • 10.4 Social reward (praise for practising behaviour during and between intervention training sessions) Enablement • 3.1 Social support (unspecified) (buddy identified at 1st training to provide ongoing support) |
 Some midwives did not consider referral to Quitline to be effective [24]. | Reflective motivation Beliefs about consequences | Education Persuasion | Education • 5.1 Information about health consequences (that referrals to Quitline result in x% increase in quit attempts/rates) Persuasion • 9.1 Credible source (delivered by Quitline staff or other cessation experts) |
 Some midwives have concerns about damaging the client relationship [23, 24]. | Reflective motivation Beliefs about consequences | Persuasion Modelling | Modelling • 6.1 Demonstration of the behaviour (video showing engaged client and effective midwife) Persuasion • 5.1 Information about health consequences and 5.3 information about social and environmental consequences and 6.3 information about others’ approval (professional patient describing health and emotional (not valued) consequences of midwife not addressing their smoking—gives impression OK to keep smoking) • 9.1 Credible source (above information delivered by a pregnant or postpartum woman who smoked) |
 Prioritising other health issues (e.g. gestational diabetes) over smoking [23]. | Reflective motivation Goals | Persuasion | Persuasion • 5.1 Information about health consequences and 5.2 salience of consequences (impact of smoking relative to another condition they manage well, e.g. diabetes) • 9.3 Comparative imagining of future outcomes and 13.2 framing/reframing (reframing action for smoking by comparing with action for other conditions) |
 Framing smoking as a social issue/lifestyle choice rather than an addiction (and therefore not my role) [23]. | Reflective motivation PR&I | Education Persuasion | Education • 5.1 Information about health consequences (impact of nicotine on the brain and role in addiction) Persuasion • 9.3 Comparative imagining of future outcomes (comparison with their successful responses to other behavioural issues, e.g. domestic violence) • 13.2 Framing/reframing (reframing smoking as a behavioural indicator for intervention rather than a ‘lifestyle choice’) |
 Some midwives are uncomfortable asking about smoking [23, 24]. | Automatic motivation Emotion | Persuasion Modelling | Modelling • 6.1 Demonstration of the behaviour (video showing engaged client and effective midwife) Persuasion • 5.1 Information about health consequences and 5.4 information about social and environmental consequences (professional patient describing health and emotional (not valued) consequences of midwife not addressing their smoking) • 9.1 Credible source (professional patient) • 5.4 Information about social and environmental consequences (other midwives feel good about professional role after delivering 5As) • 9.1 Credible source (midwifery champion) |
Enablers | Â | Â | How these were used to support the intervention |
 Knowledge of harms associated with smoking was reasonably good [23, 24]. | Psychological capability Knowledge | Education Training Enablement | It was agreed not to address this specifically in our intervention as knowledge of harms was reasonably good and is also covered in the HETI modules, and there were more pressing issues to address |
 Midwives have good communication skills generally and are a trusted source of information for women [23]. | Psychological capability Cognitive and interpersonal skills | Education Training Enablement | This enabler was fundamental to the overall intervention which leverages midwives’ excellent communication skills and strong trusting relationships with women to address smoking. It was specifically used in addressing the barriers related to lack of confidence to deliver the 5As |
 5As can be delivered while carrying out other clinical tasks [23]. | Physical opportunity Environmental context and resources | Training | Some midwives had described how they provided the 5As while undertaking clinical tasks, so we developed a video to demonstrate this, and included a discussion of the ways in which this could be achieved in the workshops |
 The EMR prompts to ask about smoking at the initial visit [23]. | Physical opportunity Environmental context and resources | Environmental restructuring | This was recognised as an important first step in identifying smokers and was considered in addressing the barrier related to the lack of systems to identify smokers at subsequent visits and reminding clinicians to deliver the 5As, and in the barrier regarding the lack of systems for monitoring for quality assurance purposes. We identified a number of options using ‘Environmental Restructuring’ to address this (see above and text) and subsequently contributed to enhancements to the EMR to address this. |
 Some clinicians reported increased role satisfaction from delivering 5As [23, 24]. | Reflective motivation Professional role and identity | Persuasion | This was used to address the barrier that some midwives were uncomfortable asking about smoking, by developing a video resource with midwives talking about their satisfaction and the professional benefits of addressing smoking |