Providing smoking cessation support for Aboriginal pregnant women and mothers Acknowledgement of Country We acknowledge the Aboriginal custodians of the land we meet on today. We pay our respects to the Elders past and present, and extend that respect to Aboriginal people present today. INTRODUCTION TO YARNING ABOUT QUITTING
Why was Yarning about Quitting (YaQ) developed? Because some of the Aboriginal women we see are smokers Quitting smoking early in pregnancy is best for mother and baby Health professionals want to provide information, advice and support to help women quit BUT, raising smoking and providing quit support can be challenging Yarning about Quitting aims to address common challenges and provide practical skills for health professionals supporting Aboriginal women to quit
Whats in the YaQ learning package? eLearning module For NSW Health staff HETI Online For other participants link to module on the NSW Kids and Families website Face to face training (4 hours) Practical focus learning and applying skills in providing effective and culturally appropriate quit support Who is the YaQ learning package for? All health professionals working with Aboriginal women,
women having Aboriginal babies, and Aboriginal families YaQ builds on existing resources Yarning about Quitting is a tailored package It does not cover all aspects of brief intervention, smoking and pregnancy, or motivational interviewing However, elements from each of these topic areas have been incorporated into Yarning about Quitting Yarning about Quitting DVD - Introduction Watch the Yarning about Quitting DVD Introduction As you watch, jot down some of the messages you are
hearing from the health professionals and women who appear. Key messages Quitting is one of the most important things a woman can do to improve her and her babys long-term health. Pregnancy is a good time to talk about smoking women can be more motivated to quit. Engagement / rapport / trust is critical but can take time keep tapping away. Aboriginal women expect to be asked about
smoking during pregnancy and offered support to quit. Quitting usually takes a few attempts support from health professionals over time is important. The rate of smoking during pregnancy is higher for Aboriginal women. Smoking in pregnancy increases the risk of miscarriage, prematurity, low birth weight, birth complications and health problems for the baby/ child (e.g. respiratory issues, ear infections, behavioural issues).
Its important to keep asking about smoking a womans perspective can change over time. Continuing to offer quit support shows we care about the health of the woman, her baby, and her family. Exploring challenges Work in small groups (at your table) Use a mud map to write down at least three things you find challenging when raising smoking and supporting Aboriginal women to quit
Challeng es Common challenges Afraid to raise (or continue raising) smoking worried about loss of trust / hassling / pushing the woman away.
Working with women experiencing complex social issues wonder if quitting smoking is a priority? Good at building rapport / providing positive reinforcement but find it hard to take the next step - assisting the woman to identify practical and acceptable
strategies for quitting. Being too keen to jump to giving advice and to solving a womans problems without taking the time to build rapport, listen to the womans story and elicit her own solutions. Unsure how to engage / assist in a culturally appropriate way may make you overly cautious about raising smoking
May be a smoker yourself and feel hypocritical or unable to have the conversation about quitting Negative views about smoking and the potential for women to successfully quit nobody quits, its
not worth the time and effort to keep raising the issue What does research tell us? We are not starting from scratch Most Aboriginal smokers (men and women) that health professionals see: Will want to quit Already know that smoking and passive smoking are harmful Are likely to already live in smoke-free homes and
Have a history of recent quit attempts. Aboriginal women expect antenatal care to include smoking cessation advice and feel support from health professionals is likely to be helpful with quit attempts Aboriginal women express strong protective attitudes to the fetus and look up to positive role models
What does research tell us? Aboriginal women can face significant barriers to quitting Social and cultural norms Stressful and challenging life circumstances Limited specific knowledge about the harms from smoking and about treatment options - such as Nicotine Replacement Therapy (NRT) and how to use it System barriers Lack of subsidy for oral forms of NRT Excessive caution used in prescribing NRT
Further reading The information in the previous two slides was sourced from three published articles: Gould, G. S., Bittoun, R., & Clarke, M. J. (2014). A pragmatic guide for smoking cessation counselling and the initiation of Nicotine Replacement Therapy for pregnant
Aboriginal and Torres Strait Islander smokers. Journal of Smoking Cessation Passey, M. E., Bryant, J., Hall, A. E., Sanson-Fisher, R. W. (2013). How will we close the gap in smoking rates for pregnant Indigenous women? Medical Journal of Australia Thomas, D. P., Davey, M. E., Briggs, V. L., Borland, R. (2015). Talking about the smokes: summary and key findings. Medical Journal of Australia Links to these articles are included on your Related training and resources handout along with another recommended article: Kimber, P. R., & Ellerbeck, E. F. (2014). Its time to change the
default for tobacco treatment. Addiction Guidelines for treatment of smoking in pregnancy Guidelines for treatment of smoking in pregnancy Evidence-based information from: Managing Nicotine Dependence: a guide for NSW Health staff and Gould, Bittoun and Clarkes published article Pragmatic guide for smoking cessation counselling and initiation of NRT for
pregnant Aboriginal and Torres Strait Islander Smokers General principles Encourage quitting early in pregnancy Encourage quitting rather than cutting down Share information using simple educational materials Talk about stress in a way that is easily understood Talk about withdrawal symptoms Work with a woman to identify triggers for smoking and provide practical strategies that are captured in a personal Quit Plan Offer support to other cohabitants who smoke
Check back in with the woman Nicotine Replacement Therapy Consensus of expert opinion - NRT is much safer than continuing to smoke during pregnancy RACGP Guidelines and NSW Health Guidelines if quitting with behavioural support alone is unsuccessful, NRT should be considered and offered Intermittent forms of NRT (gum, lozenge, inhalator, mist, spray) preferred to patch in the first instance Higher dose NRT (4mg gum not 2mg) required due to pregnant womans increased metabolism
Nicotine patch can be used if oral is problematic (nausea) or if combination therapy is required (e.g. for highly dependent smokers) Practical tips about NRT If initial attempt to quit cold turkey is not successful (this attempt or previous attempt) move swiftly on to NRT Explain in simple terms how NRT works Have samples of NRT on hand so you can show clients how to use it Check in with a woman daily (especially for first 5 -7
days) when she starts on NRT Be prepared to alter the NRT type or dosage if it is not working for the client For further information on NRT Refer to Managing Nicotine Dependence: a guideline for NSW Health staff Seek advice from colleagues with specialist knowledge The more you understand and are familiar with NRT, the more comfortable you will be offering appropriate treatment for you clients
Supporting Aboriginal women to quit The importance of yarning Take a moment to think about. What does it mean to have a yarn? Why is it important to take the time to yarn? Yarning. Allows you and the woman you are meeting with to get
to know each other a little Shows that you are genuinely interested in the woman and that you care for her, her baby, and her whole family (not just ticking boxes) Is sometimes mostly about listening Gives you the opportunity to hear the womans unique story Provides a foundation makes asking about smoking (and other health issues) more relaxed / conversational Recognising culture and history
Having a yarn is a great approach with any woman But it can be especially important for Aboriginal women Cultural norms History of negative experiences with hospitals/ institutions Learning more Yarning about Quitting DVD Respecting the Difference Talk with your colleagues Supporting Aboriginal women to quit
Counselling skills Communication styles Directing < ---- > To Guiding - Point - Accompany - Kindle
- Inspire - Elicit - Offer < ---- > Following To - Allow - Listen - Understand - Grasp - Stay with - Value
Some examples of a Directing Style include: Telling Explaining Making suggestions
Prescribing Warning Persuading Persuasion: is never helpful and leads to the woman saying Yes but....... The Righting Reflex Comes from the heart, good intentions and the desire to fix things, but
It leads to resistance, lowers confidence and blocks problem solving You become the expert and your client becomes the passenger Ambivalence Ambivalence occurs when the woman has two conflicting thoughts and feelings at the same time These are expressed by: 1)
2) Change talk which is language that points to: Arguments for change Possibilities of change and Positive things that could help with change Sustain talk which is language that favours keeping things as they are Closed questions
lead to Yes and No answers Are you thinking of quitting? Have you tried NRT? Do you smoke in the house? Open questions often start with: - What, How, Tell me more about The type of information that open questions should provide What thoughts have you had about cutting down or quitting? Should tell us how important she thinks this is
What is your understanding of NRT? or What is your experience of NRT? Should provide information for the planning stage Tell me about the places you like to smoke? Should elicit information about house and car environment and smoking triggers How to adopt a following / guiding style using OARS
O = Ask Open questions A = Affirm the positive R = Listen Reflectively S = Summarise the important points Benefits of open questions Establishes a collaborative partnership and working relationship that allows the change process to unfold Encourages the woman to think about and express her
hopes, concerns, knowledge and beliefs Allows you to gather information about: Her smoking history Specific thoughts she may have in regard to quitting in the past, now or in the future Affirm (A in OARS) To affirm is to acknowledge and highlight the positive things the woman has said
Affirmation is an expression of: A desire, reason or need to change I have been thinking about the babys health.. Her abilities and strengths I can be quite stubborn when I make my mind up Insights, hopes, supports My family are everything Affirmation is not praise. Affirmations must be linked to something specific, for example: Youve been thinking about it and thats a great place to start Youve achieved a smoke free house and car, that is a positive
step And the tone or intensity should match the behavior: Try not to over respond with an overly emotional tone to small changes, for example: Oh wow that is fabulous, well done you!!! Instead use simple statements with a suitable tone, that points to the behavior: You have cut down by half thats a great effort Reflection or reflective listening (R in OARS) Reflective listening involves feeding back to the woman
Certain words or short statements using her words or your own words Reflective listening: Demonstrates that you are truly listening and trying to understand Allows the woman to hear again her thoughts and feelings being expressed by another person Encourages the woman to say more and dig deep Enables you to check for points of detail and interpretation Is a way to demonstrate empathy or understanding
Examples of reflective statements Youre trying ...........pause Being a role model is important to you ........pause Sounds like in the past you have tried but found it too hard .........pause Other important forms of Listening Nods...Mmmm. Oh I see Yes I understand Silence / the pregnant pause (5-10 seconds) Summarising (S in OARS)
Summarising: Is where you gather or collect the important things the woman has said and hand them back, as in a basket It can be used to form links between information gathered at an earlier time and with what is happening now It is particularly useful to begin and end an interview And to transition from one topic to another Or to transition into the planning phase See handouts for more information and examples Focussing the interview
Focussing is the process by which you: Develop and maintain a specific direction in the conversation about change Encourage movement towards a particular goal or topic Bring the conversation back to important points raised or yet to be raised Shift gears toward goal setting and planning I understand how stress is a big issue, but for now, could we spend some time looking at your strengths, your determination or stubbornness - I think that's what you called it earlier. Perhaps we could come up with some options or a possible plan?
Planning And finally at some point we must shift gears and focus on the planning process Things to consider: Does the woman appear ready to embark on the process or Does she display signs that she is not ready In this case using mostly sustain talk Questions like: How important does she think the change is and How confident does she feel .may need to be addressed again
Assessing importance and confidence will be demonstrated later Planning Even if a woman does not appear ready, it is essential that every attempt is made to: Maintain rapport By asking permission before you educate, give advice, etc. I understand that youre not ready right now but is it OK if we spend some time looking at Raise hope or the possibility of change If quitting was somehow made easier how would that be?
This could give you a lead into offering NRT Keep the door open and discuss possible plans for the future Decide together a baby step that could be tried During this process continue to follow OARS Activity
Work in pairs with someone you do not know Pick a behaviour that you have been considering changing: Cut down/quit smoking Eat more fruit and vegetables Eat less take away Get more exercise Watch less TV Lose some weight etc..... You will have 5 minutes each to practice OARS The practitioner needs to hold a pen to remind them not to give any advice or suggestions
Applying knowledge and skills Yarning about Quitting DVD Scenarios Putting learning into practice Yarning about Quitting DVD three scenarios As we watch each scenario: Keep in mind what you have learnt in the workshop Refer to your handouts Think about: What is being done well?
What you might have done differently? What else you would have done to support the woman? Scenario 1 - Chrissie Young Aboriginal woman First pregnancy First antenatal visit with a midwife (Tracy) at her local hospital Opening the conversation How do you think Tracy (the midwife) is going so far? What has Tracy done well?
Would you have done anything differently? A good start Tracy demonstrated good rapport building Tracy raised smoking in a conversational way and explored the topic with Chrissie using open questions How do you find being pregnant and being around family members who smoke? What have you heard about smoking and pregnancy? Tracy gave non-judgemental responses E.g. when Chrissie said she smoked, Tracy replied
I want you to feel comfortable to say that and know that we are here to support women who smoke in pregnancy. Tracy might have said. So you said youve cut down, can you tell me a bit more about that, how have you been doing that?
So you said youve cut down, what's changed? About how many cigarettes were you smoking a day before and how many are you having now? This could then lead into a few more questions to assess Chrissies smoking Sharing information Tracy used a clear, simple visual aid when talking with Chrissie
Tracy did not minimise the risks Sometimes people working in health worry about the womans feelings when delivering information about risk We can deliver facts and still maintain relationship and remain non-judgmental Tracy used an open question to check in with Chrissie and see what she thought/felt about the information Chrissie Scene 2 We have just heard Chrissie say that she wants to quit Lets see what Tracy does next
As you watch, think about What steps is Tracy taking to support Chrissies quit attempt? What else might you have done to give Chrissie the best chance of success? What was done well Asking Chrissie to think about / say what support she might need to quit (before offering any advice) Reinforcing that quitting is recommended in pregnancy Introducing the option of NRT early If Chrissie is finding quitting without assistance difficult
Linking Chrissie to Quitline Making the call together Checking in with Chrissie at the end to see how she is feeling What else might have assisted Chrissie? Asking a few more questions Chrissie, have you tried to quit before? If you have, how did that go? What do you know about what can happen when you try to quit? This can lead into sharing information about withdrawal symptoms and talking about times she is likely to find not smoking difficult
Working with Chrissie to make a plan Identifying triggers / challenging situations and strategies to manage these What will she do if quitting cold turkey gets too hard? Putting clear steps in place What else might have assisted Chrissie? Clearly outlining follow-up Someone needs to call Chrissie within three days to see how she is going Let Chrissie know who she can call if she needs help
Encouraging Chrissie to make contact / come back no matter how the quitting is going Advising that quitting can take a few attempts Letting her know that support can be provided over time But this is a booking-in appointment! There is a lot to get done at a booking-in appointment, but Asking about smoking Doing a brief smoking assessment Providing information about the risks of smoking in pregnancy, and
Offering quit support .are all things that can and should happen at the first antenatal visit However, comprehensive quit support requires a team approach Scenario 2 - Marlene Aboriginal woman, 26 weeks pregnant Third antenatal visit (home visit) with a midwife (Evelyn) and an Aboriginal health worker (Josie) As you watch the first part of this scenario, listen and jot
down the important cues you hear from Marlene Whats happened so far? Josie and Evelyn have opened the conversation well How are you going Marlene? (good rapport building) How you been going with the jummin?(open question) They have also provided some information about the link been nicotine withdrawal and stress But there were opportunities to explore some of Marlenes responses a bit more What important information did Marlene share?
Cues from Marlene Feeling tired and stressed Charlie has been in hospital recently (asthma) Tried to quit before (not clear when that was) Looking for the smokes more since shes been pregnant
Trying not to smoke as much but that makes her feel more stressed Stress as a barrier to quitting The stress caused by not smoking may not be understood as nicotine withdrawal effects A visual guide can be a good way to help a woman understand that the stress she is feeling may be nicotine withdrawal Source: Gould, G. & Munn, J. (2012). Give up the smokes Aboriginal quit caf: a new concept in intensive quit
support for Aboriginal and Torres Strait Islander people training manual. Importance - confidence - readiness Another strategy is to use scaling questions to measure a womans importance and confidence for change (to establish their readiness for change) Ask: On a scale of 1-10, how important is it for you to make a change? 1 2
3 4 5 6 7 8 9 10 _______________________________________________ Not at all important Extremely Important
Importance - confidence - readiness Ask: If you were to make a change, on a scale of 1-10, how confident would you be to make a change? 1 2 3 4 5 6 7 8
9 10 ________________________________________ Not at all important Important Extremely Lets now return to Marlene Evelyn and Josie can hear Marlenes sustain talk, but they are trying to keep the conversation going.
A reminder about praise Evelyn and Josie want to acknowledge a positive step by Marlene But they have missed an opportunity to affirm and explore An example: A smoke free house/car is such an important step for the familys health, well done. It requires a bit of planning and determination, how you go about it? What were your reasons? Sounds like when you make up your mind to do something, you do it.
did Watch now as Evelyn and Josie try to help Marlene make a start with quitting by talking about NRT As you watch, jot down: What you think Evelyn and Josie do well? What else you might have done to give Marlenes NRT trial the best chance of success? What was done well? The offer of NRT was linked to Marlenes concerns
managing withdrawal while cutting down (what feels to Marlene like stress) Good information exchange about NRT explaining how to use the lozenges and taking time to respond to Marlenes questions/concerns about NRT What else could assist Marlene? Assist Marlene to devise a more specific plan, for example: We spoke about different ways a person can use the lozenges, what do you reckon you could try? If there are cigarettes that feel easier not to have, you could begin by having a lozenge instead of those.
Or you could have the lozenges every 1-2 hours from when you wake up - try to delay your first smoke a bit more each day. What do you think might work best for you? Discuss, explore but let the woman find the best option It is important that she expresses a plan in her words own What else could assist Marlene? Once Marlene has agreed on a plan, check how she is
feeling about this, for example: So given all we have spoken about how are you feeling about giving the NRT a go? Does it feel easy or hard or a bit of both? If she feels it will be hard for her, it probably wont succeed Lets have another look at this Assist her to devise a more reasonable plan What else could assist Marlene? Reflect back Marlenes decision and be very clear about follow-up, for example
Marlene, youve decided to give NRT a go and have come up with a really good plan. Well done. Well call you tomorrow and see how you are going. Remember, there are different types of NRT, so if you find that the lozenges arent working well for you, we can try another product. Well now watch a second scene with Marlene This is the same visit we were just watching, but Marlenes husband (Bill) has come home for lunch, and Evelyn and Josie have taken the opportunity to talk with him about Marlene giving oral NRT a go.
Bill has asked Josie about her smoking What did you think about Josies response? Do you smoke? Respond honestly I do still smoke, but I am trying to quit and have managed to cut down using NRT. Note your role as a health professional and return the focus to the client As a health professional, I understand the risks of smoking and want to help as many women as I can to quit. Lets talk a bit more about.(return to
something relevant to the client) Scenario 3 - Lisa Aboriginal woman, 32 weeks pregnant Clinic visit with midwife (Skye) and Aboriginal health worker (Sharan) As we watch scene 1 Listen to Lisas responses to Skye and Sharans questions Jot down the important information you hear Lisa share Some great examples Open questions, summarising, and focusing
In terms of your cigarettes, how are we going there? So how have you been doing that? Last time we met, we talked about. So if you were in that instance, what would you do? Important information from Lisa Very motivated to quit (determined to do it, wants a healthy baby) Lozenges have helped a bit Now smoking 3-5 cigarettes a day Finds it hard not to smoke in the morning and when
around friends Thinks that she just needs to try harder / have more will power How would you approach assisting Lisa at this point? Explore smoking triggers You said that you find it hard not to smoke in the morning and when you are around friends, can we talk about that a bit more? Whats hard about those times? You said that you are smoking three to five smokes a day, can you tell me about when you are having those smokes?
Then you can explore strategies to avoid have a cigarette Behavioural strategies, not just trying harder (Lisa is already trying very hard!) Tailoring NRT You said that the lozenges have helped a bit, can you tell me about when do they work well and when they dont seem to help? How have you been using them? By exploring Lisas triggers and when the NRT is (and is not) working, you have a good foundation to offer specific NRT options that fit with Lisas circumstance
We are now going to watch all of scene 2, where you will see Skye and Sharan offer Lisa assistance As you watch Think about how this compares to some of the ideas we have discussed How did Skye and Sharan go? Lisa has been offered additional NRT Good explanation of how to use the patches Quit line offered and explained well
However, a few more questions were needed Smoking triggers Experience with NRT to date This could lead into focussing Identifying with Lisa the most appropriate NRT options and behavioural strategies to address her specific barriers to quitting How did Skye and Sharan go? More detailed planning would also assist What is Lisa specifically going to do when she leaves
today? When will Sharan or Skye follow-up next? Who will Lisa contact if she needs more help? And finally, checking in How does Lisa feel about what she is going to try? Is it realistic / achievable? Yarning about Quitting train the trainer workshop Wrapping up Questions?
Opportunity to raise any questions that you havent asked yet today For further information / questions after today, contact: [INSERT YOUR CONTACT DETAILS] Thank you! Please take a few minutes to complete the workshop feedback form .while watching the Yarning about Quitting DVD Conclusion.. Acknowledgements
Yarning about Quitting was developed in partnership by NSW Kids and Families, the Health Education and Training Institute (HETI), and the Centre for Population Health With thanks to: Training and Support Unit for Aboriginal Mothers, Babies and Children (TSU) Central Coast Local Health District Hunter New England Local Health District
Sydney Local Health District Illawarra Shoalhaven Local Health District Northern NSW Local Health District Artwork Western NSW Local Health District Raechel Saunders, Biripi Nation Aboriginal Health and Medical Research Council of NSW Aboriginal Quitline NSW & ACT
Dr Gillian Gould, Australian Association of Smoking Cessation Professionals Ms Tracey Greenberg Ms Darron Webber Ms Vivian Cain Associate Professor Megan Passey Professor Sandra Eades References Gould, G. S., Bittoun, R., & Clarke, M. J. (2014). A pragmatic guide for smoking cessation counselling and the initiation of Nicotine Replacement Therapy for pregnant Aboriginal and Torres Strait Islander smokers. Journal of Smoking Cessation, pp. 1-10. doi: 10.1017/jsc.2014.3
Gould, G. S. & Munn, J. (2012). Give up the smokes Aboriginal quit caf: a new concept in intensive quit support for Aboriginal and Torres Strait Islander people training manual. Mid North Coast (NSW) Division of General Practice and Galambila Aboriginal Health Service Kimber, P. R., & Ellerbeck, E. F. (2014). Its time to change the default for tobacco treatment. Addiction, pp. 381-386. doi: 10.1111/add.12734 NSW Ministry of Health. (2015). Managing nicotine dependence: a guide for NSW Health staff. North Sydney: NSW Ministry of Health Passey, M. E., Bryant, J., Hall, A. E., Sanson-Fisher, R. W. (2013). How will we close the gap in smoking rates for pregnant Indigenous women? Medical Journal of Australia, 199 (1), pp. 39-4. doi: 10.5694/mja12.11848 Thomas, D. P., Davey, M. E., Briggs, V. L., Borland, R. (2015). Talking about the smokes: summary and key findings. Medical Journal of Australia, 202 (10), pp. S3-S4. doi:10.5694/mja15.00464
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