Table 3 Barriers and levers to implementation of 5 A-QUIT-N intervention

Clinical level

Clinical practices

Posture

Has a trusting relationship and positive attitude towards pregnant woman

X

X

Takes pregnant woman into account as a whole

X

X

Takes pro-active approach during every contact with pregnant woman

X

Multi-professional

Builds multi-professional partnership

X

X

Establishes communication between stakeholders (professionals, partners)

X

X

Knows network of local stakeholders

X

X

Makes available list of stakeholders who can provide care

X

Clinical support tools

Uses motivational interviewing

X

X

Produces informational materials for pregnant women

X

X

Promotes existing communication tools (e.g. in waiting rooms)

X

Clinical level

Representations of 5 As model

Takes doubts of professionals about the effectiveness of the 5 As model into account

X

X

Provides information on effectiveness of referring

X

Clinical level

Professional role and identity

Perceived role

Clarifies importance of tobacco management during pregnancy follow-up

X

Encourages professionals to embrace their role

X

X

Motivation

Builds on interest and motivation of professionals for 5 As model and its implementation

X

X

Builds on willingness of professionals to change smoking behaviour

X

Pays particular attention to the fact that gynaecologists do not feel concerned by prevention

X

Involves midwives and nurses

X

Self-efficacy

Improves self-efficacy of professionals

X

X

Improves legitimacy of professionals regardless of their personal smoking status

X

Clinical level

Representations of pregnant women by HPs

Takes the representation of smoking as a choice into account

X

Takes negative perception of pregnant woman into account

X

X

Takes fear of losing relationship with pregnant woman into account

X

X

Takes accessibility of health system for pregnant women (geographical and economical) into account

X

Clinical level

Influence of beneficiaries

Takes lack of knowledge about health effects of tobacco on women and children into account

X

X

Takes lack of motivation of pregnant women into account

X

X

Takes underestimation of difficulty of smoking cessation into account

X

Takes dissatisfaction of pregnant women with professionals into account

X

Organisational level

Organisation of practices

Healthcare pathway

Uses time in waiting room for smoking prevention

X

X

Uses time during examination for smoking prevention

X

Integrates smoking cessation into pre-existing consultations

X

X

Offers consultations dedicated to tobacco management

X

Deployment

Develops a 5 As model deployment protocol

X

Involves managers in communication in relation to the 5 As model

X

X

Involves expert opinions in communication of the 5 As model

X

Sets up monitoring of implementation of the 5 As model

X

Adapts intervention according to existing local resources

X

Organisational level

Resources

Financial resources

Takes cost of implementation into account

X

X

Time resources

Takes time available into account

X

X

Prioritizes issues to be addressed during perinatal consultations

X

Takes patient's comorbidities into account

X

Organisational level

Support for professionals

Training

Follows training on the 5 As model

X

X

Acquires skills (e.g. having a positive attitude towards woman's smoking history, communicating on risks for the foetus, implementing each step of the 5 As model)

X

Acquires knowledge (e.g. on NRTs, on addictions and on specific risks of tobacco on the foetus)

X

Resources for professionals

Develops clinical guidelines

X

X

Develops and disseminates expert recommendations

X

X

Sets up automatic computer reminders

X

Trains professionals in the 5 As model to support perinatal professionals

X

Provides feedback on the practices of professionals

X

Health system level

Political environment

Involves patient organisations (advocacy)

X

Has commitment from management

X

X

Makes smoking cessation a priority (support from management teams, authorities, expert groups, etc.)

X

X

Takes local complexities (succession of plans, need for global coherence and concrete measures) into account

X

Sets up referents in health care institutions

X