Qualitative Interviews With Nurses in Appalachian Ohio Regarding Prenatal Smoking

The Central Appalachian area of Southeast Ohio has a higher rate of tobacco-related women’s health issues, smoking, low birth weight and preterm birth than other parts of the state and the nation. Prenatal smoking continues to be one of the most common preventable causes of infant morbidity and mortality in the United States, including pre-term birth and low birth weight (Dietz, England, Shapiro-Mendoza, Tong, Farr, & Callaghan, 2010; Seybold, Broce, Siegal, Findley & Calhoun, 2012). Smoking during pregnancy is a particular problem in Ohio, with 16.3% of women still smoking in the third trimester (ODH, 2012), twice as high as the national rate of 8.4% (Curtin & Mathews, 2016). No qualitative studies published in the past 10 years were found regarding smoking during pregnancy in Appalachia.

The purpose of this study was to learn more about the cultural influences and the special needs in Appalachia to inform the development of culturally appropriate women’s health promotion and smoking cessation interventions. Nurses in Appalachia can provide a bridge for health care providers who are not from the region to understand the perspectives of people who reside in Appalachian counties.

Methods: Purposive sampling was employed to recruit nurses in Southeast Ohio who work with women in the perinatal period. However, the participants were not from the same social network. Semi-structured small focus group and individual interviews were conducted with 14 nurses working with pregnant women in Appalachia. Participants were asked about women’s health issues, smoking, and smoking cessation interventions in relation to their knowledge and experience of their home county.

Data Analysis: Interviews were audiotaped, then transcribed verbatim. The constant comparison method was used with the organizational aid of qualitative data management (NVivo 9, QSR International). A Southeast Ohio native was on the analysis team. Content analysis involved extraction of major concepts, themes, and patterns. Two persons independently analyzed the data, then compared their coding and resolved differences.

Results: Themes fell into 4 categories: Reasons People Smoke, Reasons People Quit, Barriers to Quitting, and Perceptions of Current Interventions, including the Public Health Service guidelines on tips for smoking cessation. Subthemes revealed Ambivalence of health care providers toward tobacco use, Difficulty of quitting tobacco with smokers in the household and social network, and Reactions to PHS guidelines for people in this region. Table 1 shows themes, subthemes, and representative quotes.

Discussion/Conclusion: Challenges to be addressed in women’s health promotion activities in Central Appalachian areas include the multiple competing demands on time and energy and the strong influence of family in a more collectivistic culture. Smoking cessation interventions developed using the information gathered should incorporate issues salient to this population such as the social acceptability of smoking, smokers in the household and the desire for gradual smoking cessation. Although gradual cessation is not part of the National Health Service guidelines, Seybold (2012) showed that reduction of smoking during pregnancy improved outcomes in a sample of Central Appalachian women. Graham (2014) showed in a meta-synthesis that most of those interviewed found reduction for gradual cessation to be useful among pregnant women in English-speaking countries. The needs revealed in this study should be considered in smoking cessation interventions to positively impact the increased smoking-related morbidity and mortality experienced in Central Appalachia.

Table 1: Themes

Themes	Subthemes	Quotes
Reasons People Smoke	Stress Management	“And I think it’s a big part of life for a lot of people in this County… that’s just what they do. That’s what I use for stress relief.”
	Social Environment	“I am a current smoker,… and I think all my kids smoke, so I don’t think it has broke the cycle any, so.”
	Addiction	“And then they’re addicted and can’t stop even if they wanted to.”
Reasons People Quit	Health	“We all know it’s bad for you, I learned that in Kindergarten! That’s why it surprises me that so many people my age smoke.”
	Financial	“Some say the cost makes them want to quit, but most people seem like they always can get money for cigarettes.”
Barriers to Quitting	Ambivalence of Healthcare Providers	“My aunt’s obstetrician told her that after a certain time in the pregnancy the stress of quitting is more harmful than continuing to smoke…..she quit anyway.”
	Smokers in the Household	“Being isolated from friends and family that smoke is a very painful experience and may have material consequences, like on living quarters.”
Perception of Current Interventions	Quit Date	“I think setting a goal is helpful, but 2 weeks seems like a very short time to get used to not smoking.”
	Total Abstinence	“People I know that have quit has done it gradually.”
	Remove Tobacco from Your Environment	“My family defined your everything…We grew tobacco on the side, in the 80s we could get a good price. At the age of 15 you were allowed to start smoking, all of us, … smoking at once. Still a major part in a lot of my family members’ houses.”