Hassanein, Zeinab M.
(2023)
Prevention of second-hand smoke exposure among pregnant women and children in Egypt and the rest of the Middle East: a mixed-methods investigation.
PhD thesis, University of Nottingham.
Abstract
Second-hand smoke (SHS) exposure is a major public health concern. Pregnant women and children are a priority population for tobacco control efforts because second-hand smoke (SHS) exposure during pregnancy/childhood poses serious risks to foetal/child health. Due to strong cultural constraints against women smoking in many Middle Eastern countries, the prevalence of tobacco smoking is higher among men than women, which puts non-smoking women and children on risk of exposure to SHS. The Middle Eastern countries are Bahrain, Cyprus, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Palestine, Qatar, Saudi Arabia, Syria, Turkey, United Arab Emirates, and Yemen.
In Egypt, daily SHS exposure among pregnant non-smoking women and children is estimated to be more than 50% at home and more than 70% in public places. The aim of the current thesis is to investigate the experience of SHS exposure among pregnant women and children in Middle Eastern countries with focus on Egypt, barriers and facilitators to reduce it, and to come up with recommendations on how to reduce this exposure. Three studies were conducted to achieve this aim.
The first study aimed to identify, appraise, and synthesize the evidence related to experiences and views of parents, children, and professionals on the prevention of second-hand smoke exposure to women and children in Middle Eastern countries by conducting a qualitative systematic review. Six databases and grey literature were searched from inception to January 2021 to identify published and unpublished studies. No language restrictions were applied. The JBI guidelines for qualitative systematic reviews were followed in conducting the review, with a meta-aggregation process was used to synthesize findings and ConQUAL used to summarise the confidence in the findings. Of 5229 records identified, two qualitative studies (in three publications) met the eligibility criteria and were included in the review. One study was conducted in Turkey and the other study (reported in two papers) was conducted in Israel. The methodological quality of the studies was high based on the JBI critical appraisal tool for qualitative research. The participants in the included studies were parents (n=118 participants) aged between 18 and 42 years. One of the included studies did not differentiate in quotations between mothers and fathers. The methods used for data collection within the included studies were interviews, which were analysed using thematic analysis. A total of 50 findings were extracted and aggregated into eight categories, based on the similarity of meaning. Three synthesized finding were generated, all with moderate confidence: i) Parents were aware of SHS exposure and that exposure is harmful, although the health dangers of SHS exposure were not commonly discussed with parents by Healthcare Professionals (HCPs) during pregnancy; ii) Smoking is a socially and culturally accepted norm, with parents reporting cultural beliefs about traditional values as a barrier to reducing SHS exposure in the home. Parents also reported personal psychological barriers to quitting smoking; iii) Parents implemented different physical restrictions on smoking, such as having rules about where smoking can take place at home, but tended to lack certainty or confidence regarding whether such protective measures were needed or would be effective. As this systematic review found that SHS exposure is not commonly discussed with parents during pregnancy by HCPs, it recommends standardized guidelines to be available for HCPs in primary health centres to help them to guide parents regarding SHS exposure during pregnancy and childhood.
HCPs are well placed to help reduce exposure to SHS in pregnant women and children. HCPs spend a significant amount of time in contact with pregnant women throughout their pregnancy and can therefore enquire about their SHS exposure, advise them to prevent SHS exposure, and encourage their husbands to quit smoking. Advice from HCPs on managing and reducing SHS has been shown to be effective in previous studies and it is advisable to be implemented in Middle Eastern countries.
Thus, the second study in this thesis aimed to explore knowledge, attitudes and counselling practices of HCPs working in maternal and child health (MCH) clinics in Egypt in relation to the prevention of SHS exposure among pregnant women and children. A survey of HCPs working in public maternal and child health clinics in Assiut city, Egypt was conducted in August 2020. Descriptive and regression analyses were performed to identify the factors related to high levels of knowledge, supportive attitudes and self-reported good counselling practice. 367 HCPs participated in the study (response rate=68.5%), 12% of whom were smokers. The majority of respondents were nurses (45%). Approximately half of HCP reported a high level of knowledge about the dangers of SHS exposure (56%), a supportive attitude towards preventing SHS exposure (53%), and having good counselling practice regarding SHS exposure (52%). Being a General Practitioner (GP) (OR 15.29, 95%CI 4.12-56.86), serving urban communities (OR 2.53, 95%CI 1.53-4.18) and being exposed to SHS at home (OR 2.36, 95%CI 1.48-3.78) were significantly associated with high knowledge compared to gynaecologists/obstetricians, and HCPs serving urban communities, respectively. Being female (OR 2.02, 95%CI 1.27-3.24), serving rural communities (OR 1.58, 95%CI 1.01-2.49), and not being exposed to SHS at home (OR 2.36, 95%CI 1.29-3.10) were significantly associated with a supportive attitude towards the prevention of SHS exposure compared to male HCPs, serving urban communities, and exposed to SHS at home, respectively. Being female (OR 1.53, 95%CI 1.15-2.63), serving a rural population (OR 2.37, 95%CI 1.41-4.01), receiving previous training on smoking cessation services (OR 2.80, 95%CI 1.50- 5.22), not being exposed to SHS at home (OR 2.35, 95%CI 1.42-3.89), and having a supportive attitude (OR 5.51, 95%CI 3.40-8.94) towards prevention of SHS exposure were significantly associated with good counselling practice compared to being male HCPs, serving urban population, not receiving previous training on smoking cessation, being exposed to SHS at home and not having supportive attitude towards prevention of SHS exposure respectively. The main obstacles to providing counselling as reported by HCPs were lack of time and training, unavailability of relevant materials, and absence of reimbursement. This study concluded that knowledge, attitudes and practice of HCPs regarding the risks of SHS to pregnant women and children in Egypt should be improved. Training for HCPs alone is unlikely to be sufficient due to the range of issues identified as needing to be addressed, including the lack of time and unavailability of relevant materials. Moreover, clear specification of SHS counselling service should be incorporated in the job description of HCPs working in public MCH centres by health system governors.
The third study was a qualitative study which aimed to explore barriers to preventing SHS exposure among pregnant women/children and smoking behaviour at home in Egypt. Six focus group discussions (FGDs) with pregnant women/mothers of children residing in urban/rural areas were conducted in August 2020. Data were coded and analysed using the framework approach. Sixty-one participants were recruited, aged 18–49 years. All participants reported being never smokers and the place of exposure to SHS to themselves and their children was mainly in the home. Pregnant women and mothers had some general knowledge of the dangers of SHS. The most commonly reported barriers to preventing SHS exposure/adopting a smoke-free home or workplace were social acceptance of smoking and SHS exposure, masculinity and gender norms of accepting smoking among men as a normative behaviour, fear of damaging their relationship with family, women resigning themselves to SHS exposure, and doctors not being supportive of smoking cessation. The majority of interviewees’ families were reported to allow smoking anywhere in the home; others implemented some measures to prevent SHS; however, these tended to be inconsistently implemented and were unlikely to be effective. This study concludes that changing the gender norm of accepting men to be smokers as a normative behaviour among Egyptian society could protect pregnant women and children from SHS and help to reduce burden caused by tobacco use. Where household smokers are unwilling or unable to quit, families should be offered support to make their homes completely smoke-free.
The current thesis concludes that there is a need for de-normalization of SHS exposure in Egyptian society. Better enforcement of smoke-free policies is essential. There are missed opportunities for HCPs to provide guidance and support to pregnant women and mothers regarding reducing and managing exposure to SHS exposure; therefore, there is an urgent need for HCPs to support smoking cessation services in primary health centres settings. SHS policy, practice and research should focus on educating and providing smoking cessation support to husbands/fathers since they are identified as the main the source of SHS. It is important that the wider environment is made conducive to increase the awareness and willingness of HCPs to provide support on smoking cessation and prevention of SHS exposure, such as the enforcement of smoke free polices and other population level intervention such as anti-tobacco mass media campaign.
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