The experience and cessation needs of Indigenous women who smoke during pregnancy: a systematic review of qualitative evidence protocol

Review objective and questions The aim of conducting this review is to identify and synthesize the best available evidence to address two questions: (1) what is the experience of smoking during pregnancy for Indigenous women? and (2) what are the smoking cessation needs of Indigenous women who smoke during pregnancy? Background Although the overall prevalence of smoking has declined in many countries in recent years,1 smoking remains a major public health concern.2 In fact, the World Health Organization has described tobacco use as a global epidemic because of its continued and high prevalence in many countries worldwide.1,3 Smoking among Indigenous peoples is of particular concern.4 What is known about smoking prevalence in Indigenous peoples is largely based on reports from Western countries, namely, Canada, the United States, Australia and New Zealand. In these countries the prevalence rate of smoking among Indigenous peoples is higher than that in the general population; in some cases it is two to three times higher.5–9 Smoking is a leading cause of preventable morbidity and mortality within many countries. It is an important risk factor for three of the most common causes of death among adults: heart disease, lung cancer and chronic lung disease,10,11 and is causally linked to many other diseases.12 Research indicates that smoking harms nearly every organ in the body.13 Half of all long-term smokers die prematurely from tobacco-related diseases.14 Many people who smoke have a reduced quality of life from the chronic and debilitating health effects and from the financial burden it creates.12,13 Smoking contributes to the impoverishment of disadvantaged people, not only because of the cost of purchasing tobacco, but also the loss of wages due to smoking attributed-illness and death, and the cost of treating such illness.2,15,16 Smoking during pregnancy is of even greater concern. This is because not only does smoking adversely affect the pregnant woman's general health, it also adversely affects pregnancy outcomes and the health of the fetus and the child after birth and into childhood and adult years. Smoking during pregnancy has been found to be causally related to such serious consequences as placenta previa, placenta abruption, pre-term delivery, low birth weight and sudden infant death. Moreover, it has been found to be causally related to cleft lip and cleft palate, and impaired lung function in childhood.12,14,17 There is also evidence to suggest an association with other congenital abnormalities, behavioral disorders in childhood (e.g. attention deficit hyperactivity disorder),12,14 and overweight and obesity in childhood with related risks for cardiovascular and metabolic disorders later in life.18–21 In addition, women who smoke during pregnancy tend to smoke in the postpartum period,22–24 which exposes breastfed babies to nicotine25 and exposes infants to second-hand smoke if the mother smokes in their presence. Second-hand smoke from parental smoking is causally associated with childhood lower respiratory illnesses, asthma, recurrent otitis media and chronic middle ear effusion. As with smoking during pregnancy, exposure to second-hand smoke is a causal factor for sudden infant death and for lower lung function in childhood.17 Despite a decline in smoking in pregnancy in Western countries in recent years, prevalence rates continue to be alarming, with population reports indicating that approximately 9 to 13% of women smoke during pregnancy.24,26–29 Similar to the discrepancy in smoking rates between Indigenous populations and non-Indigenous populations generally,6–9 smoking rates during pregnancy are considerably higher among Indigenous women than among other women. In Canada 47% of First Nations30 and 56% of Inuit31 women, compared with 10.5% of women in the general population,29 smoke during pregnancy. In the United States 18 to 26% of American Indian and Alaska Native women smoke during pregnancy compared with 12.9 to 14.3% of White women.27,32 In Australia 50% of Aboriginal and Torres Strait Islander women smoke during pregnancy compared with 11.7% of non-Indigenous women.28 In New Zealand 34% of Maori women smoke during pregnancy compared with 11% of women in the general population.26 As concerning as the Indigenous figures are, they may be conservative estimates as they are based on self-reports. It is well acknowledged that women's self-reports tend to underestimate the actual rate of their smoking during pregnancy.33–35 Women might be reluctant to disclose that they smoke or might minimize the extent of their smoking because of the stigma associated with smoking during pregnancy.36–38 Other reasons could be emotional discomfort from knowing the health impacts or a desire not to discuss quitting.35 A number of factors are associated with smoking during pregnancy. Those most commonly recognized, both within Indigenous and non-Indigenous populations, include low-income, low educational level and unemployment, along with other sources of social stress,28,29,32,39–42 factors that pervade Indigenous peoples.43,44 Within Indigenous populations generally, there are specific historical, cultural and social factors that have been identified as important influences on the high rates of smoking: the introduction and commoditization of tobacco by colonists,45,46,47 exploitation of Indigenous peoples and dispossession of Indigenous lands by colonists,46 a high level of normalization of smoking and concomitant high exposure to smoking in Indigenous communities,42,46–50 Indigenous peoples' value of smoking as a social experience and a way to connect and maintain relationships,46,47,49,50 and inadequate attention to smoking prevention and cessation services and programs for Indigenous peoples.46,51–53 Although some Indigenous peoples use tobacco for traditional medicinal or ceremonial purposes, it is the habitual use of commercial tobacco that is addictive, harmful and of concern.51 Although many women who smoke when they become pregnant quit at some point during pregnancy, a considerable number continue to smoke, whether at the same or a reduced level. Quit rates in national studies of pregnant women are in the area of 52 to 55%.22,23,32 However, quit rates are lower in pregnant women who are socioeconomically disadvantaged.32,54 In studies of pregnant Indigenous women, specifically, quit rates of 10 to 30% were found.28,30 It has been suggested that pregnancy is “a window of opportunity” to assist women to quit smoking because of their contact with health professionals for antenatal care55(p. 26) and because attachment to their unborn child56 and concern for the child's health may be a strong motivator for quitting.38,48,57,58 However, there is little in literature about smoking cessation interventions for pregnant Indigenous women and little is known about intervention suitability and effectiveness.59 Because of the high rate of smoking among Indigenous peoples, they shoulder a disproportionate burden of smoking-attributed morbidity and mortality compared with non-Indigenous populations.60 Given the high rate of smoking during pregnancy among Indigenous women and the consequent serious health effects, it is important to examine the experience of smoking during pregnancy for these women and to examine their smoking cessation needs. A preliminary review of literature indicates that some qualitative studies exist in which smoking during pregnancy among Indigenous women was addressed. It is anticipated that the proposed systematic review of such studies will enable an understanding that will ultimately inform recommendations for culturally appropriate smoking cessation interventions for pregnant Indigenous women. Based on a search of literature in the Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports and in the Cochrane Library, PubMed, PROSPERO, and DARE databases, a systematic review has not be conducted to date on the experience of smoking during pregnancy for Indigenous women or their smoking cessation needs. Inclusion criteria Type of participants This review will consist of studies that include Indigenous women who smoke or smoked during pregnancy and who live in communities worldwide. The studies may be of Indigenous women solely or may include non-Indigenous women also, as long as data can be extracted on the Indigenous sample. The commonly accepted understanding of the concept Indigenous used by the United Nations will be applied to identify studies conducted on the participants of interest. Indigenous peoples are found in 70 countries from the Arctic to the South Pacific, and given the diversity of the peoples, a single official definition is not appropriate.61 However, there are commonly accepted criteria that are used to determine who Indigenous peoples are. The main criterion is self-identification as Indigenous at the individual level and acceptance by the Indigenous group as one of its members.62 Other criteria are that Indigenous peoples are peoples who: “Demonstrate historical continuity with pre-colonial and/or pre-settler societies. Have strong link to territories and surrounding natural resources. Have distinct social, economic or political systems. Maintain distinct language, cultures and beliefs. Form non-dominant groups of society. Resolve to maintain and reproduce their ancestral environments and systems as distinctive peoples and communities".44 In some countries, there may be a preference to use other terms, rather than Indigenous, such as Aboriginal, First Nations, First Peoples, and Tribes.61 Phenomena of interest The phenomena of interest for this review are the experience of smoking during pregnancy for Indigenous women and the smoking cessation needs of Indigenous women during pregnancy. Therefore, studies in which one or both of those phenomena were examined will be considered for inclusion in this review. Types of outcomes The outcomes for this review are the voiced experiences of smoking for pregnant Indigenous women, their voiced cessation needs, and recommendations for actions that could help them quit smoking. Types of studies The studies that will be considered for this review are those in which qualitative data were gathered and analyzed on the phenomena of interest and include, but are not limited to, the following designs: qualitative description, phenomenology, grounded theory, ethnography, action research, feminist research and mixed methods research. Search strategy A three-step search strategy will be employed in this review to find both published and unpublished studies. An initial limited search of PubMed and CINAHL will be undertaken followed by an analysis of text words contained in the title and abstract and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Language limits will not be applied in the search strategies. However, only studies published in the English language will be considered for inclusion in this review. Any published non-English studies will be documented and reported in the review. Date limitations will not be imposed on search strategies. The databases to be searched consist of the following: PubMed, CINAHL, PsycInfo, Embase, Sociological Abstracts, SocINDEX, and Web of Science. Unpublished studies will be sought through direct contact with authors and through searching ProQuest Dissertations and Theses, MEDNAR, Google Scholar, OpenGrey, OAIster, Google, and websites for relevant research institutions, government agencies, and non-government organizations. Initial keywords for the search will consist of the following: tobacco use, smoking, smoking cessation, expectant mothers, pregnancy, Indigenous, Aboriginal, First Nations, Native, Indian, tribe, experience, perception, perspective, narrative, interview, field study, focus group, audio-recording, observational method, qualitative, phenomenology, grounded theory, ethnography, mixed methods and content analysis. The search strategy will be implemented by the health sciences librarian on this review in consultation and collaboration with the other reviewers. Assessment of methodological quality Papers selected for retrieval will be independently assessed by the primary and secondary reviewers, that is, the first and second authors, for methodological validity prior to inclusion in the review. A standardized critical appraisal instrument, the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI), will be used (Appendix I). The reviewers will be blinded to each other's assessments of the studies. Once the assessments are completed, the primary reviewer will compare the two assessments for each study. Any discrepancies between the assessments will be resolved through discussion between the two reviewers or in consultation with the other reviewers and a decision will be made to include the study or not include it in the review. Data collection Data will be extracted from papers included in the review using the standardized Joanna Briggs Institute Data Extraction Instrument (JBI-QARI) (Appendix II). The data extracted will include specific details about the phenomena of interest, populations, study methods and outcomes relevant to addressing the review questions. Authors of studies will be contacted to clarify or seek additional data as necessary. The data will be extracted from each study by the primary reviewer in collaboration with the secondary reviewer. The other reviewers will be consulted should questions arise concerning the data. Data synthesis Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality and categorizing these findings on the basis of similarity in meaning. These categories will then be subjected to a meta-synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for informing evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form. The data synthesis will be conducted by the primary reviewer in collaboration with the secondary reviewer. The other reviewers will be consulted for their input and the findings will be confirmed through team discussion. Conflicts of interest The authors declare no conflicts of interest. Acknowledgements We would like to thank the School of Nursing, Memorial University of Newfoundland, for supporting our Joanna Briggs Institute training in systematic reviews.

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