Designing an implementation intervention with the Behaviour Change Wheel for health provider smoking cessation care for Australian Indigenous pregnant women

Abstract

Background
Indigenous smoking rates are up to 80% among pregnant women: prevalence among pregnant Australian Indigenous women was 45% in 2014, contributing significantly to the health gap for Indigenous Australians. We aimed to develop an implementation intervention to improve smoking cessation care (SCC) for pregnant Indigenous smokers, an outcome to be achieved by training health providers at Aboriginal Medical Services (AMS) in a culturally competent approach, developed collaboratively with AMS.

Method
The Behaviour Change Wheel (BCW), incorporating the COM-B model (capability, opportunity and motivation for behavioural interventions), provided a framework for the development of the Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy implementation intervention at provider and patient levels. We identified evidence-practice gaps through (i) systematic literature reviews, (ii) a national survey of clinicians and (iii) a qualitative study of smoking and quitting with Aboriginal mothers. We followed the three stages recommended in Michie et al.’s “Behaviour Change Wheel” guide.

Results
Targets identified for health provider behaviour change included the following: capability (psychological capability, knowledge and skills) by training clinicians in pharmacotherapy to assist women to quit; motivation (optimism) by presenting evidence of effectiveness, and positive testimonials from patients and clinicians; and opportunity (environmental context and resources) by promoting a whole-of-service approach and structuring consultations using a flipchart and prompts. Education and training were selected as the main intervention functions. For health providers, the delivery mode was webinar, to accommodate time and location constraints, bringing the training to the services; for patients, face-to-face consultations were supported by a booklet embedded with videos to improve patients’ capability, opportunity and motivation.

Conclusions
The ICAN QUIT in Pregnancy was an intervention to train health providers at Aboriginal Medical Services in how to implement culturally competent evidence-based practice including counselling and nicotine replacement therapy for pregnant patients who smoke. The BCW aided in scientifically and systematically informing this targeted implementation intervention based on the identified gaps in SCC by health providers. Multiple factors impact at systemic, provider, community and individual levels. This process was therefore important for defining the design and intervention components, prior to a conducting a pilot feasibility trial, then leading on to a full clinical trial.

Full text

R E S E A R C H Open Access
Designing an implementation intervention
with the Behaviour Change Wheel for
health provider smoking cessation care for
Australian Indigenous pregnant women
Gillian S. Gould
1*
, Yael Bar-Zeev
1
, Michelle Bovill
1
, Lou Atkins
2
, Maree Gruppetta
1
, Marilyn J Clarke
3
and Billie Bonevski
1
Abstract
Background: Indigenous smoking rates are up to 80% among pregnant women: prevalence among pregnant
Australian Indigenous women was 45% in 2014, contributing significantly to the health gap for Indigenous Australians.
We aimed to develop an implementation intervention to improve smoking cessation care (SCC) for pregnant Indigenous
smokers, an outcome to be achieved by training health providers at Aboriginal Medical Services (AMS) in a culturally
competent approach, developed collaboratively with AMS.
Method: The Behaviour Change Wheel (BCW), incorporating the COM-B model (capability, opportunity and motivation
for behavioural interventions), provided a framework for the development of the Indigenous Counselling and Nicotine
(ICAN) QUIT in Pregnancy implementation intervention at provider and patient levels. We identified evidence-practice
gaps through (i) systematic literature reviews, (ii) a national survey of clinicians and (iii) a qualitative study of smoking and
quitting with Aboriginal mothers. We followed the three stages recommended in Michie et al.’s“Behaviour Change
Wheel”guide.
Results: Targets identified for health provider behaviour change included the following: capability (psychological
capability, knowledge and skills) by training clinicians in pharmacotherapy to assist women to quit; motivation
(optimism) by presenting evidence of effectiveness, and positive testimonials from patients and clinicians; and
opportunity (environmental context and resources) by promoting a whole-of-service approach and structuring
consultations using a flipchart and prompts. Education and training were selected as the main intervention
functions. For health providers, the delivery mode was webinar, to accommodate time and location constraints,
bringing the training to the services; for patients, face-to-face consultations were supported by a booklet embedded
with videos to improve patients’capability, opportunity and motivation.
Conclusions: The ICAN QUIT in Pregnancy was an intervention to train health providers at Aboriginal Medical Services
in how to implement culturally competent evidence-based practice including counselling and nicotine replacement
therapy for pregnant patients who smoke. The BCW aided in scientifically and systematically informing this targeted
implementation intervention based on the identified gaps in SCC by health providers. Multiple factors impact at
systemic, provider, community and individual levels. This process was therefore important for defining the design and
intervention components, prior to a conducting a pilot feasibility trial, then leading on to a full clinical trial.
Keywords: Behaviour Change Wheel, Smoking cessation, Pregnancy, Health provider training, Indigenous populations
* Correspondence: Gillian.Gould@newcastle.edu.au
1
School of Medicine and Public Health, University of Newcastle, University
Drive, Callaghan, NSW 2308, Australia
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Gould et al. Implementation Science (2017) 12:114
DOI 10.1186/s13012-017-0645-1
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Background
Implementation science is the study of the methods to
promote the systematic uptake of evidence-based prac-
tice into routine care to improve the quality and effect-
iveness of health services [1]. In this case, the challenge
was to implement what is known to be effective for
smoking cessation care (SCC) during pregnancy, into
the context of health providers working with Indigenous
women served by Aboriginal Community Controlled
Health Services (ACCHS).
Indigenous smoking rates are high during pregnancy:
in some communities, up to 80% of pregnant women
smoke or use tobacco in another form [2]. In Australia,
pregnant Indigenous women smoke at almost four times
the rate of their non-Indigenous counterparts (45% com-
pared to 12% in 2014) [3]. Smoking prevalence of preg-
nant Australian Indigenous women has been slow to
decline, and cessation rates in pregnancy are half those
of non-Indigenous counterparts [3].
Impediments to smoking cessation are complex in this
setting and reveal individual-, community- and system-
level factors [4]. A very high baseline prevalence of
smoking among Indigenous families and communities is
one factor that may jeopardise the capacity of individual
people to quit [5]. Other important factors perpetuating
Indigenous tobacco smoking in Australia include the
detrimental impact of European colonisation causing
dispossession, degradation and loss, and during which
tobacco was introduced to many Indigenous communi-
ties for the first time; how Indigenous workers were
often only paid in tobacco; government policies such as
children being forcibly removed from parents (termed
‘the stolen generation’); and racism [2]. Tobacco smok-
ing has become a norm and a social lubricant in many
and diverse Australian Indigenous communities [2]. Des-
pite these factors, more Indigenous smokers want to quit
smoking than their general population counterparts but
are less likely to succeed [6, 7]. Another important factor
is the necessity to develop a strategy to address the
needs of health professionals, who have been reported to
seldom perform all the recommended steps for smoking
cessation care for pregnant women [8, 9].
Theory-based interventions are recommended when
designing complex approaches to behaviour change and
aid in the specification of potentially active ingredients
[10]. In defining the components of such an interven-
tion, an analysis of the target behaviour is a key [11].
Smoking cessation in pregnancy, in particular for Indigen-
ous populations, is an example where multiple factors
have been identified that could be critical when designing
targeted approaches to smoking cessation [4, 12]. A lack
of evidence for successful smoking cessation interventions
for pregnant Indigenous populations highlights the im-
portance of understanding context when designing
intervention components, and using a systematic ap-
proach to avoid implementation challenges [5].
Evidence-based smoking cessation care
There is robust evidence that a combination of two ap-
proaches, the use of counselling and appropriate forms of
pharmacotherapy, produces better outcomes than each
alone in the general population of smokers [13]. Nicotine
replacement therapy (NRT) is the most appropriate type
of smoking cessation pharmacotherapy in pregnancy [14].
Emerging evidence from Cochrane Reviews indicates that
counselling and NRT are effective in pregnancy [5], al-
though these approaches have not yet been shown to be
efficacious in Indigenous pregnancies. However, only two
randomised controlled trials have been conducted globally
in Indigenous pregnant women [15–17].
The Indigenous Counselling and Nicotine QUIT in
Pregnancy intervention
The Indigenous Counselling and Nicotine (ICAN) QUIT
in Pregnancy is an evidence-based smoking cessation
implementation intervention, developed primarily as a
training intervention for health providers through webi-
nar. It aims to support health providers to provide cul-
turally targeted smoking cessation care to pregnant
Indigenous smokers, attending Aboriginal Medical Ser-
vices. Resources were developed to aid the implementa-
tion of the provider-patient consultation process (to aid
counselling and provision of NRT) and included three 1-
h interactive webinar sessions with PowerPoint presenta-
tions and short embedded videos, a training manual, a
flipchart and a desktop guide (as a mouse pad). As part
of the implementation, pregnant patients were to be pro-
vided a combined educational and motivational booklet
with augmented reality videos within print media, and
an educational and motivational video that could be
watched in the clinic waiting room. Patient instructions
for NRT were included in the patient information book-
let by video and text. In addition, the implementation
intervention provided free samples of NRT, and free
courses of oral forms of NRT for the women to be pre-
scribed at the services, and audit and feedback for the
services about prescribing rates of NRT.
These resources developed through the process out-
lined below, went on to be reviewed by an expert panel
and tested in several focus groups with health providers
and Aboriginal women in three Australian states [18].
The resources then underwent a series of refinements
[18]. Throughout this iterative process, extensive con-
sultation and negotiation processes occurred, working
closely with Aboriginal Medical Services and a Stake-
holder and Consumer Aboriginal Advisory Panel [19].
In order to design the ICAN QUIT in Pregnancy im-
plementation intervention and to address previous
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implementation challenges (revealed by similar trials for
Indigenous women during pregnancy [15–17]), the Be-
haviour Change Wheel (BCW) [20] and the Theoretical
Domains Framework (TDF) were used [21]. These
models were used to design a service-level approach,
which would address the evidence gaps and provide a
targeted approach for smoking cessation care at the
health provider (HP) and patient levels.
Underpinning models and frameworks
Behaviour Change Wheel
The BCW is a parsimonious model synthesising many
behaviour change theories (see Fig. 1) [20]. At its hub is
the COM-B model, which expands to capability (C), op-
portunity (O) and motivation (M)—these are all needed
to produce or change a behaviour (B) [20]. The COM-B
model recognises that behaviour is part of an interacting
system involving an individual’s or group’s capability
(physical and psychological), opportunity (social and
physical) and motivation (reflective and automatic). A
mid ring on the BCW comprises nine intervention func-
tions, and on the outer ring, there are seven policy-level
strategies. The BCW is used to link influences on behav-
iour, identified by the COM-B, to potential intervention
functions and policy categories.
Theoretical Domains Framework
The TDF is an implementation science model compris-
ing 14 domains that can categorise influences on behav-
iour [21]. These include the following: ‘Knowledge’,
‘Skills’,‘Social/Professional Role and Identity’,‘Beliefs
about Capabilities’,‘Optimism’,‘Beliefs about Conse-
quences’,‘Reinforcement’,‘Intentions’,‘Goals’,‘Memory, At-
tention and Decision Processes’,‘Environmental Context
and Resources’,‘Social Influences’,‘Emotions’and ‘Behav-
ioural Regulation’. According to Michie et al., links be-
tween the BCW and TDF can be utilised in the analysis
and design of targeted interventions [11].
The BCW and TDF have been used previously to ana-
lyse health provider and patient or consumer behaviour;
for example, Alexander et al. used the TDF and the COM-
B to analyse barriers to the use of the Healthy Kids Check,
introduced by the Australian Government in 2008 to
guide the health screening of pre-school children by GPs
and nurses [22]. Gould used the BCW to analyse barriers,
enablers and strategies to improve smoking cessation care
for pregnant Indigenous women [4].
The BCW is emerging as an important tool to rigor-
ously develop interventions prior to clinical trials. The
TDF and BCW have been used to systematically develop
complex interventions in other populations and for
other behaviours: several targeted health provider behav-
iour [23–28]. Sinnott et al. used the BCW to develop an
intervention to improve medication management in
multimorbidity by GPs, by uniquely developing a collab-
orative shared decision-making approach between peers
[26]. McSharry et al. developed a multilevel intervention
to increase delivery of sexual health counselling by car-
diac rehabilitation staff [25]. Murphy et al. used the TDF
and BCW to develop a capacity-building program to en-
hance pharmacists’roles in mental health care [27]. The
latter focused on health provider training, using a train-
the-trainer approach. Similar to our approach, Murphy
et al. highlight the iterative and fluid nature of the devel-
opmental process, which is challenging to capture. Rele-
vant to our study, researchers applied the BCW and
COM-B model at both the provider and patient levels to
develop interventions to encourage long-term hearing
Fig. 1 The Behaviour Change Wheel (reproduced with permission from authors) [11]
Gould et al. Implementation Science (2017) 12:114 Page 3 of 14
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aid use [24] and to encourage nurse-led physical activity
in patients [21, 28]. More specifically for smoking cessa-
tion, for example, the BCW was used to develop a mo-
bile phone App to encourage patients to use UK Stop
Smoking Services, prior to a full trial of the intervention
[29], and an App to support smoking cessation among
pregnant women [30].
Indigenous-specific factors
In addition to the BCW and TDF, two factors appear to
be relevant for developing Indigenous-specific ap-
proaches related to tobacco control and smoking cessa-
tion. A factor analysis of 47 organisations developing
tobacco control messages for Indigenous Australians re-
vealed two important, yet separate factors of ‘cultural
understanding’and ‘rigour’. Aboriginal Medical Services
demonstrated strength in their cultural understanding
while universities and government organisations demon-
strated strength in rigour. A combination of cultural un-
derstanding and rigour was applied by few participating
organisations. However, these two important factors
emerging from the analysis can be seen as an opportun-
ity to bring the best of two worlds together—Indigenous
and Western viewpoints [31].
Methods
Aim, design and setting
The aim of this study was to describe (1) how imple-
mentation and intervention components for the ICAN
QUIT in Pregnancy were developed for health provider
and patient behaviour change based on the TDF and
BCW and (2) comment on the translation of current evi-
dence from smoking cessation care during pregnancy in
conjunction with Indigenous researchers and an Abori-
ginal community advisory panel, and relevant to an Indi-
genous context.
This study was based on a growing body of evidence in-
cluding systematic reviews by Okoli et al. about the
provision of smoking cessation care by health providers
[9] and by Baxter et al. about the uptake of smoking cessa-
tion care by pregnant women [26, 32], which demon-
strated gaps in delivery of elements of SCC from the
provider and patient viewpoints, and a systematic review
by Gould et al. about Aboriginal women’s views of smok-
ing during pregnancy [33]. Several narrative explorations
of the influences on smoking among Indigenous women
including two analyses using the BCW [2, 4, 34, 35], and
empirical studies from both health providers’and Indigen-
ous women’s views about knowledge, attitudes and prac-
tices, were considered [36–40].
Materials and processes
We conducted further research to refine our under-
standing about practices from the health provider view
and the patients’viewpoints. Thus, we based our initial
intervention design on several studies. These included
the following:
1. A systematic review of knowledge, attitudes and
practices of health providers globally in providing
smoking cessation care for pregnant women. The
review, (currently being conducted) includes self-
report from the health providers, observational
studies and women’s reports of the care they
received. Seventy-nine papers were included: 53
quantitative, 24 qualitative and 2 mixed methods.
A meta-analysis was performed of pooled estimates of
how often health providers perform each of the 5As
(‘Ask’,‘Advise’,‘Assess’,‘Assist’,‘Arrange’), and pre-
scribing rates of NRT. Qualitative data was extracted
forananalysisofissuesregardingsmokingcessation
care and the use of NRT, according to the BCW and
COM-B, from the 24 qualitative and two mixed
methods paper.
2. A systematic review of 23 included papers about
interventions to improve health providers’smoking
cessation care for pregnant women, globally (in
process)
3. A survey of 378 general practitioners (GPs) and
obstetricians’knowledge, attitudes and practices
related to smoking cessation care for pregnant
women. This included an analysis using the TDF and
revealed several components of SCC that were less
than ideal or missing, for example assisting pregnant
women to quit and prescribing suitable forms of
pharmacotherapy [8]. (Results are summarised
below in the section on step 2 of the process.)
4. A qualitative study of 20 Aboriginal women who
were pregnant or had recently given birth and were
smoking or ex-smokers. The study focused on the
women’s narratives of smoking before, during and
after pregnancy and their attitudes and experiences
of accepting smoking cessation care and pharmaco-
therapy [29,41,42].
Thus, we took into consideration multiple studies
on Indigenous pregnancy from researchers in this
field [12, 33, 36, 38, 39, 43–46], identifying the fol-
lowing major factors:
Smoking by Indigenous women during pregnancy is
a complex challenge and has multiple contributing
factors.
Clinicians ask and advise about smoking but less
frequently assess, assist and arrange follow-up.
Clinicians report a lack of confidence and optimism
for helping their pregnant patients stop smoking.
NRT prescription rates are also low.
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Aboriginal pregnant women report deficiencies in
being provided important elements of smoking
cessation care, such as being prescribed NRT, and
being given consistent messages.
In the developmental phase of the implementation
intervention, we considered approaches to modify both
health provider behaviour, so that they more consistently
provide evidence-based smoking cessation care to Indi-
genous women, and Indigenous women’s behaviour re-
garding their tobacco smoking practices during
pregnancy. The health providers of interest were those
working within the ACCHS in Australia. These included
GPs, midwives, nurses, Aboriginal Health Workers and
other relevant allied health professionals.
The research team was multidisciplinary and included
Aboriginal and non-Aboriginal researchers from med-
ical, social science, art, public health, behavioural science
and education backgrounds. The team developed the re-
sources collaboratively over several months and in con-
sultation with a Stakeholder and Consumer Aboriginal
Advisory Panel through a community-based participa-
tory action research process [19]. The process of the
intervention development, while guided by the stated
theoretical frameworks, was iterative and fluid and
evolved over several months of working within the core
research team and the broader group of stakeholders.
Use of the BCW and TDF by the research team
Using the BCW to translate the evidence into a cultur-
ally competent approach and guide the implementation
intervention design, we followed the three stages recom-
mended in Michie et al.’s“Behaviour Change Wheel”
guide and associated worksheets [11]. Two of the team
(GG and YBZ) attended a BCW training course run by
the book’s author and our co-author (LA).
Figure 2 shows the schema of the three stages and the
composite steps in each, according to the BCW guide
[11].
Results
The results from this analysis are structured according to
the recommended stages and steps for intervention design,
as described by Michie et al., and designated in Fig. 2 [11].
Designing approach to health provider behaviour
change
Stage 1: understand the behaviour
Step 1: define problem in behavioural terms
A conceptual model (Fig. 3) depicts the multiple factors
that influence smoking behaviours and smoking cessa-
tion among Indigenous women [2, 4, 12, 33–36, 38–40,
42, 44, 46–49]. These factors have an impact at the sys-
temic level, provider level and community and individual
levels. Although work is going on to attempt to remedi-
ate some of these factors (such as the policy-level lobby-
ing to improve access and affordability of oral forms of
NRT), this intervention is focused on translating the
evidence-based practice for SCC in pregnancy to the In-
digenous context.
Health provider behaviours
We identified the behavioural problem as a lack of es-
sential elements in the health providers’provision of
evidence-based SCC for pregnant Indigenous women
who smoke, such as prescribing NRT, providing cessa-
tion support, involving family members and following
up. Health providers are required to provide SCC to
pregnant women who smoke. The Australian RACGP
guidelines recommend initially using supportive counsel-
ling, but if the woman cannot quit, she can be also of-
fered NRT to assist cessation [50].
A systematic review by Okoli et al. [9] and our own
systematic review (Gould 2017, unpublished data) re-
vealed that while health providers often ‘Ask’and ‘Advise’
about smoking cessation to pregnant women, they less
commonly ‘Assist’women to quit smoking. A lack of
support from health providers for smoking cessation
during pregnancy was cited as a barrier in previous re-
search, with Aboriginal women and other vulnerable
groups [41, 51].
The variety of health providers needing to improve ac-
cess to SCC within the ACCHS is manifold. Depending
on the stage of pregnancy, and the services themselves,
women will see several different health professionals.
We considered all health providers within a service
would need to have the same over-arching approach for
SCC, so the women would not receive conflicting advice.
Thus, a whole-of-service approach was considered.
Step 2: select the target behaviour
Several evidence-based practices are recommended for
SCC, including the 5A’s(‘Ask’,‘Advise’,‘Assess’,‘Assist’and
‘Arrange’) [50], the ABC (‘Ask’,‘Brief advice’,‘Cessation’)
[11] [52] and the AAR (‘Ask’,‘Advise’,‘Refer’) [53]. Gould
et al. proposed that health providers should take a holis-
tic approach to SCC for pregnant Aboriginal women
and recommended using an ABCD approach—A (Ask/
assess), B (Brief advice), C (Cessation), D (Discuss psy-
chosocial context) [43].
A survey of 378 GPs and obstetricians’knowledge, at-
titudes and practices related to SCC for pregnant women
revealed that clinicians seldom perform the 5As of
smoking cessation (19.6% always/often) [8]. While more
perform the AAR (49.2% always/often), there are few re-
ferral options for specialised services for pregnant
women, and many are not being referred or followed up.
Clinicians fairly reliably (over 75%) asked and advised
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about smoking cessation, but only a third actually assisted
pregnant women to achieve smoking cessation. Cessation
support was provided always by 33.6%; NRT was recom-
mended/prescribed always by 11.1% and never by 25.1%.
The TDF analysis revealed that lack of optimism, lack of
time and lack of resources were the most frequently cited
barriers [8].
Similarly, a survey specifically with health providers
working with Aboriginal pregnant mothers revealed that
only 4.7% recommended NRT to most or all pregnant
clients who smoked [40].
Furthermore, Aboriginal women in our qualitative
study revealed that they were seldom offered NRT, and
when an offer did occur, it was as a ‘one-off’offering,
and the approach and messages were inconsistent [41].
Women reported they were often told to ‘cut down’their
smoking, but rarely supported to quit [41].
A review of this combined evidence led to a decision
to primarily target the behaviour of health providers in
offering NRT to assist smoking cessation. In other
settings, assisting smokers to quit by providing a pre-
scription of NRT was more effective than providing ad-
vice (RR 1.68, 95% CI 1.48–1.89 vs. RR 1.24, 95% CI
1.16–1.33) [41, 51]. A parallel target was to support the
provision of a holistic culturally competent approach,
taking into account the social determinants of health
and psychosocial factors related to continued smoking
during pregnancy, that is exemplified in the ABCD ap-
proach [43], and thus provide resources to target the pa-
tients’needs also.
Step 3: specify the target behaviour
In specifying the target behaviour, the BCW guidebook
recommends consideration of Who, What, When,
Where, How often and with Whom. The target behav-
iour therefore would be for clinicians (Who) in the
ACCHS (Where) to proactively offer assistance to every
pregnant Indigenous smoker (Whom) to quit smoking
(What), initially by counselling, but importantly by offer-
ing NRT, if the woman was not able to achieve
Fig. 2 Stages and steps required to develop and implement an intervention according to the Behaviour Change Wheel. Adapted from Figure on
page 31, Behaviour Change Wheel—a guide to designing interventions (with permission from the authors) [11]
Fig. 3 Approaches to improve smoking cessation among pregnant Indigenous women
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abstinence in the first 2–3 days of a quit attempt
(When). This would ideally be on every occasion that a
smoker is seen (How often) until abstinence achieved.
Although some guidelines suggest women should try a
quit attempt unaided by pharmacotherapy for 2 weeks
prior to be offering NRT, we considered this inappropri-
ate in this context. It is notable that in Eades et al.’s
RCT, women were asked to do this, and between the
second and third visits, there was a dramatic drop-off in
attendance from 70 to 30% of the cohort [15]. So as not
to lose momentum in the quit attempt, and in the con-
text of wanting women to quit as soon as possible in
pregnancy, an expedited use of NRT was favoured [54].
Step 4: identifying what needs to change
Table 1 summarises the key items that required remedi-
ating for health providers, by considering the BCW, the
COM-B model and the TDF. Key areas for performance
improvement included capability (psychological skills),
motivation (optimism) and opportunity (resources/time).
According to the BCW, for this to be successful, clini-
cians would be required to increase their psychological
capability, i.e. knowledge and skills, and reflective motiv-
ation, i.e. confidence and optimism, in how to prescribe
NRT for a pregnant Indigenous woman who smokes.
Lower levels of confidence for NRT prescribing, com-
pared to counselling, were revealed in our national study
[8]. Clinicians also reported low optimism that their
treatment would be effective [53]. Thus, providers need
to build both self-efficacy and response efficacy. Further-
more, as the preferred oral forms of NRT to use in preg-
nancy are not subsidised in Australia, health providers
require improvements in their physical opportunity to
provide care, i.e. access to oral NRT supplies, in order to
effectively prescribe [47]. Clinicians understanding that
these practices are routine in other countries (such as in
Australian guidelines and programs and in other coun-
tries) may help them improve their social opportunity.
Stage 2: identify intervention options
Step 1: intervention functions
Table 1 also outlines the intervention components devel-
oped for health providers according to the analysis. Inter-
vention functions which best met the APEASE
(Affordability, Practicability, Effectiveness and Cost-
effectiveness, Acceptability, Side effects/safety, Equity) cri-
teria were considered for inclusion [11]. APEASE is a cri-
terion for making context-based decisions on intervention
content. Clinicians in our survey indicated several options
to improve their smoking cessation care (Gould 2017, un-
published). Training was an option that most of these cli-
nicians agreed on. This is supported by a Cochrane
Review that found training of HPs in smoking cessation
care increased abstinence in their patients [55]. Therefore,
education and training were chosen as the predominant
intervention function. However, to address the low opti-
mism, we include persuasion, modelling and enablement
in the intervention. Resources were also developed for the
women to support health providers in their consultations,
and to provide resources for health education, and prac-
tical assistance for their patients (described below).
Step 2: policy categories
On the policy layer of the wheel, service provision and
guidelines were our main policy targets. We wanted to
aim our approach to the whole of the ACCHS, in recogni-
tion that many health providers and allied health profes-
sions have a role in consulting with Indigenous women
during their pregnancy. We wanted smoking cessation to
be ‘everyone’sbusiness’. Furthermore, we developed a
comprehensive treatment manual that gave very practical
guidance for the approach, based on the published prag-
matic guide and the RACGP guidelines [43, 50, 56].
Stage 3: identifying content and implementation options
Step 1: behaviour change techniques
Table 1 also specifies the behaviour change techniques
(BCTs) related to the above analysis and to address each
intervention function. A taxonomy of BCTs was devel-
oped by Michie et al. (BCTTv1) as a comprehensive re-
source for intervention development [57]. Each of the 93
consensually agreed, distinct BCTs in the taxonomy are
catalogued and described in detail. The BCTs identified
for the ICAN QUIT in Pregnancy implementation inter-
vention were those which authors considered as promis-
ing to elicit behaviour change in the health providers.
In summary, to implement this smoking cessation
intervention optimally, we aimed to improve capability
by training clinicians in NRT prescribing, structuring the
consultation using a flipchart and prompts and regulat-
ing behaviour through audit and feedback (allowing so-
cial opportunity). To improve optimism, in the training,
we present recent evidence about NRT and positive tes-
timonials from patients and clinicians. We recognised
that individual clinicians may not have experienced
intervention success but needed to be exposed to that
success vicariously through other’s testimonials, so they
see that success is possible and worthwhile persisting for
(response efficacy).
Step 2: mode of delivery
To accommodate challenges around time for health pro-
viders, the large geographical area of Australia and the lim-
ited resources of the research, we decided to trial training
via interactive webinar. Webinar was chosen as a mode of
delivery with the potential to increase the reach of health
provider training to urban, rural and remote locations in
Australiaandimprovethepotential scalability. Although
Gould et al. Implementation Science (2017) 12:114 Page 7 of 14
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webinar is now a very common method of distance train-
ing, there is little research in the peer-reviewed literature
about the efficacy or effectiveness of this method. However,
we considered webinars to be affordable, cost-effective, safe,
likely to be acceptable and highly equitable. They give the
potential for face-to-face contact.
Training of short duration (40 to 120 min) has been
shown to increase smoking session outcomes in patient
Table 1 Intervention components targeting health provider behaviour
Barriers to smoking
cessation care
COM-B TDF Intervention
function
BCTs Translation of BCTs
within the ICAN QUIT in
Pregnancy intervention
Clinicians infrequently
provide cessation support
during pregnancy.
Clinicians lack knowledge,
skills and confidence to
counsel women who smoke
during pregnancy and to
prescribe NRT.
Lack of clinician training
relevant to smoking cessation during
pregnancy
Women report infrequently
receiving assistance from
clinicians
Psychological
capability
Cognitive and
interpersonal skills
Education
Training
Enablement
Information on health, social,
emotional and environmental
consequences
Information antecedents
Instruction on how to perform
behaviour
Webinar training on how
to consult Indigenous
pregnant smokers and
prescribe NRT
Training manual
Videos of providers and
patients
Memory, attention
and decision
Environmental
restructuring
Restructuring physical
environment
Prompts, cues
Flipchart and desktop
guide
Patient resources
Behaviour
regulation
Modelling
Incentivisation
Demonstration of behaviour
Feedback on behaviour
Rewarding completion
Audit and feedback
about
NRT prescribed
CPD points for training
Clinicians lack optimism
that their treatment will
be successful during
pregnancy
Reflective
motivation
Belief about
capability
Belief about
consequences
Optimism
Education
Training
Persuasion
Enablement
Information on health, social,
emotional and environmental
consequences
Credible source
Persuasion about capability
Framing/reframing
Salience of consequences
Social comparison
Adding objects to the
environment
Provide resources
Smoking reframed as an
addiction, not a choice
Inform re standard
practices and evidence-
based practices
Building self-efficacy
Build response
efficacy—it is
worthwhile—NNT only
16–17 for quitting
Motivational videos,
testimonials and success
stories
Celebrating small wins
and turning ‘near misses’
into success
Automatic
motivation
Reinforcement
Emotion
Environmental
restructuring
Persuasion
Credible source
Exposure
Framing/reframing
Social comparison
Provide resources
Emotive videos of health
providers and patients
Clinicians lack time and
resources to provide
smoking cessation care.
Oral NRT is not subsidised in
Australia forming a barrier to
prescribing
Physical
opportunity
Environmental
context
Resources
Environmental
restructuring
Enablement
Adding objects to the
environment
Problem solving
Self-monitoring of behaviour
Free NRT samples and
oral NRT vouchers
Referral pads
Flipchart and desktop
guide
Patient booklets
Few clinicians perform
comprehensive smoking
cessation care so there are
few role models
Social
opportunity
Norms
Social influences
Modelling
Education
and training
Social comparison
Credible source
Instruction on how to perform
behaviour
Self-monitoring of behaviour
Whole of service training
Interactive webinar
Audit and feedback
Videos of positive
attitudes of other health
providers
Please note: physical capability not targeted; BCT behaviour change technique; COM-B capability, opportunity, motivation-behaviour; ICAN QUIT in Pregnancy Indi-
genous Counselling and Nicotine QUIT in Pregnancy
Gould et al. Implementation Science (2017) 12:114 Page 8 of 14
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outcomes in a Cochrane Review [55]. Thus, three 1-h
webinar sessions were planned to bring the opportunity
of training to services and accommodate time and loca-
tion constraints, which may otherwise limit attendance
by the health providers. Webinar sessions were to be
interactive and include PowerPoint presentations, short
videos and group discussions. These went on to be
trialled in the pilot study in six services in three
states [58].
Design approach to patient resources
A parallel analysis was conducted to that described
above for the health providers, to address behaviour
change for pregnant patients. It was considered import-
ant to provide accompanying patient resources to sup-
port Indigenous women in their smoking cessation
journey that would also accommodate variable literacy
levels in this population. A lack of resources was also
identified by health providers. Similar to Table 1 for the
health providers, Table 2 outlines the intervention com-
ponents and behaviour change techniques we developed
for the pregnant patients who smoke, according to the
parallel analysis.
In developing the appropriate messages within the
women’s resources, we deliberately included elements of
both surface and deep structure to ensure cultural sensi-
tivity. Resnicow et al. proposed that for health messages
to be effective and culturally sensitive [59], attention
should be paid to surface structure, i.e. the look of the
messages, colours, graphics and people to enable a good
fit, and so people from a group will be engaged and
know the message is for them. Additionally, deep struc-
ture is needed to incorporate the deeper values of a
group, such as cultural and family values, and important
shared concerns and meanings: this governs the salience
of the messages [59]. In a survey of Australian organisa-
tions developing tobacco control messages, deep struc-
ture was an important factor in cultural understanding,
the use of which was characterised by Aboriginal Med-
ical Services [31].
Having salient people to deliver the messages was vital,
so we invited an Aboriginal obstetrician (Dr. Marilyn
Clarke) and a Torres Strait Islander GP (Dr. Karen
Nicholls) to deliver the health messages. Dr. Clarke ex-
plains how smoking affects babies in utero, and Dr.
Nicholls instructs women on how to correctly use vari-
ous forms of NRT. In addition, we included videos from
peers about triggers for smoking and how to make a
smoke-free home.
Discussion
This study described the developmental and translational
research to identify key components for a culturally com-
petent smoking cessation implementation intervention
aimed at educating and training health providers and pro-
viding resources to support Indigenous women to quit
smoking and support making a smoke-free home. The
BCW has been used previously to analyse and recom-
mend targeted strategies [4, 35]. We provided a more de-
tailed analysis of the theoretical components for a
smoking cessation implementation intervention for preg-
nant Indigenous Australian women, than hitherto pub-
lished, aimed principally at changing health provider
behaviour. Patten developed a smoking cessation inter-
vention for pregnant Alaska Native women after analysing
community needs and preferences and based on the social
cognitive theoretical framework [17]. Gilligan conducted
an analysis of Indigenous smoking during pregnancy with
the PRECEED-PROCEED model [60], prior to Eades et al.
consulting with general practitioners, health care workers
and community representatives in the health services to
develop an intensive intervention for pregnant Aboriginal
and Torres Strait Islander smokers [15]. Neither study
published a detailed analysis about the theoretical frame-
work used to develop the intervention.
Several papers have outlined how to optimise smoking
cessation interventions aimed at vulnerable target
groups [2, 12, 43, 48, 49, 51, 61–64]. For other condi-
tions, there has been discussion on theory informing the
development of Indigenous health programs. In an ana-
lysis of the development of anti-tobacco messages for In-
digenous Australians, 55% (n= 26) of organisations
reported using some type of theory, as one component
of a more rigorous approach [31]. However, we believe
this is the first time the BCW and TDF have been ap-
plied to the context of an Indigenous smoking cessation
implementation intervention.
The benefit of using the BCW is that it encourages
intervention designers, like us, to comprehensively and
broadly consider options to intervene and then systemat-
ically select those that are most promising for the con-
text. It aids in making the best use of the understanding
and resources available to arrive at a behaviour change
intervention [65].
Strengths and limitations
This study strengthens the theoretical foundations on
which to develop smoking cessation implementation in-
terventions for Indigenous peoples. It brings together
two important factors of cultural understanding and
rigour [31] and applies the TDF and the BCW to the
context of Indigenous smoking during pregnancy. A
limitation is the iterative nature of the process: it is hard
to capture the stepwise approach described by Michie et
al. as it can be bi-directional at times, and resulting con-
sultations within and without the core team meant that
earlier stages may be revisited, and these may not be
clearly documented. However, the Indigenous
Gould et al. Implementation Science (2017) 12:114 Page 9 of 14
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Table 2 Intervention components targeting patient behaviour
Barriers to smoking cessation care COM-B TDF Intervention
function
BCTs Translation of BCTs within the ICAN QUIT in
Pregnancy intervention
Indigenous pregnant women report symptoms of nicotine
dependence and withdrawal effects from attempts to quit.
Increased nicotine metabolism in pregnancy can increase
cigarette consumption and also requires higher doses of NRT
Physical
capability
Physical skills Education
Enablement
Provide feedback on current
behaviour and dependence levels
Assess withdrawal symptoms
Biofeedback with carbon monoxide
readings
Making a quit plan and/or setting
quit date
Advise on stop-smoking medication
Enable clients to obtain free
medication
Free NRT for physical addiction
Videos on how to use different types of NRT
Aboriginal women lack detailed knowledge about the harms
of smoking.
Stressful life circumstances may also impact on a women’s
psychological capability to quit.
Historical antecedents of smoking in Indigenous communities,
racism, health disparities and low socio-economic status can
impair capability to quit
Psychological
capability
Knowledge Education Provide information on
consequences of smoking and
smoking cessation
Instruction on how to quit smoking
Offer appropriate written materials
Health booklet, supportive counselling and
videos showing effects of smoking on
mother and child
Discuss psychosocial contexts of smoking
Cognitive and
interpersonal
skills
Persuasion Facilitate goal setting
Facilitate barrier identification
and problem solving
Facilitate relapse prevention
and coping
Facilitate action planning and
develop quit plan
Advise on conserving mental
resources
Discussion of psychosocial context of
smoking
Build self-efficacy for quitting
Culturally appropriate colouring-in pages
for diversion and relaxation
Memory,
attention and
decision
Environmental
restructuring
Enablement
Advise on avoiding social cues
for smoking
Elicit client views
Provide reassurance
Text and video on how to make a smoke-free
home
Personalised quit plan and goal setting
Patient resources
Behaviour
regulation
Enablement
Modelling
Messages from salient others—peers and
experts
NRT to reduce withdrawal effects
Carbon monoxide readings
Videos of role models
Counselling on stressors and triggers
Few positive role models, as Indigenous smoking
prevalence is high
Targeted messages preferred
Existing media messages may lack salience.
Not wanting to be ‘told what to do’.
Didactic counselling styles are unwelcome
Reflective
motivation
Social role/
identity
Belief about
capability
Belief about
consequences
Intentions
Goals
Optimism
Persuasion
Education
Enablement
Incentivisation
Modelling
Credible sources for messages
Explain the importance of abrupt
cessation
Boost motivation and self-efficacy
Rewards contingent on effort or
progress
Emphasise choice
Targeted salient messages
Build self-efficacy
Building response efficacy—stopping
smoking is worthwhile
Smoking as an addiction
Link nicotine withdrawal and symptoms
of ‘stress’
Emphasising choice to quit
Resources and support
Success stories and role models via videos
Goal setting, quit plan and quit date
Gould et al. Implementation Science (2017) 12:114 Page 10 of 14
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Table 2 Intervention components targeting patient behaviour (Continued)
Dealing with challenges
Change of role on becoming pregnancy
positively reinforces need to quit.
Protective attitudes to baby
Cravings can impair motivation
Automatic
motivation
Reinforcement Self-rewards in quit plan
Celebrating small wins
Free NRT ameliorates withdrawal symptoms
Lack of optimism for quitting Emotion Environmental
restructuring
Persuasion
Enablement
Addressing challenges in quit plan
Emotive videos
Free NRT ameliorates withdrawal/stress
symptoms
Lack of access to services or presenting late
to antenatal care
Lack of targeted resources
Lack of subsidised NRT
Health providers not frequently offering assistance
to quit
Physical
opportunity
Environmental
context
Resources
Environmental
restructuring
Enablement
Education
Advise on environmental
restructuring
Advise on changing routine
Trained providers to support their quit
attempts
Referrals to other services
Flipchart
Patient booklets
Few role models who have quit during pregnancy Social
opportunity
Social
influences
Modelling Provide normative information
about others’behaviour and
experiences
Advise on/facilitate use of social
support
Involving family members
Making a smoke-free home
Increasing social support
Positive peer role models through
video stories
BCT behaviour change technique; COM-B capability, opportunity, motivation-behaviour; ICAN QUIT in Pregnancy Indigenous Counselling and Nicotine QUIT in Pregnancy
Gould et al. Implementation Science (2017) 12:114 Page 11 of 14
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consultation and community-based participatory research
process have been described in detail elsewhere [19]. The
implementation intervention of the ICAN QUIT in Preg-
nancy will be tested in the pilot study and be adjusted as
required [58].
Implications for future research
These chosen intervention functions, mode of delivery
and resources are in the process of being trialled for
feasibility in a pilot study in six ACCHS, prior to it be-
ing implemented in a full trial [58, 66]. After this pilot
study, end-users will be surveyed and interviewed to
determine whether the intervention and study design
need any modifications before preparing for a larger
cluster randomised trial (renamed SISTAQUIT™—Sup-
porting Indigenous Smokers To Assist Quitting). The
systematic approach for the intervention development
we have described will help streamline this process.
Conclusion
Smoking during pregnancy contributes significantly to the
health gap for Indigenous Australians. Multiple contribut-
ing factors impact at systemic, provider, community and
individual levels. The ICAN QUIT in Pregnancy pilot im-
plementation intervention used webinar to train health
providers in Aboriginal Medical Services in a culturally
competent approach that includes counselling and the use
of nicotine replacement therapy for their pregnant pa-
tients who smoke. It includes culturally targeted resources
appealing to Indigenous women that can engage and also
account for low literacy by including embedded videos in
print media. Using the BCW and TDF aided in scientific-
ally and systematically informing a targeted intervention
based on the identified gaps in SCC by health providers.
This process was important for defining the design and
intervention components, prior to conducting a pilot
feasibility trial and then leading on to a full clinical trial.
Abbreviations
BCT: Behaviour change technique; BCW: Behaviour Change Wheel; COM-
B: Capability, opportunity, motivation, behaviour; GP: General practitioner;
ICAN QUIT in Pregnancy: Indigenous Counselling and Nicotine QUIT in
Pregnancy; NRT: Nicotine replacement therapy; RACGP: Royal Australian
College of General Practitioners; RCT: Randomised controlled trial;
SCC: Smoking cessation care; TDF: Theoretical Domains Framework
Acknowledgements
The authors thank the Stakeholder and Consumer Aboriginal Advisory Panel
for the ICAN QUIT in Pregnancy for advising on the intervention
components of this implementation intervention.
Funding
This work was funded by the Australian National Health and Medical
Research Council and Cancer Institute New South Wales Fellowships
awarded to GG. The funders had no role in the design of the study or
collection, analysis and interpretation of data or in the writing of the
manuscript.
Availability of data and materials
Not applicable.
Authors’contributions
GG designed the study, conducted the analysis, led the design of the
intervention components, and wrote the manuscript. YBZ contributed to the
analysis, the design of the intervention components, and the structure of the
paper. LA advised on the analysis of the intervention components and the
structure of the paper and provided training for GG and YBZ on the BCW.
MB contributed to designing intervention components and, together with
MG and MC, contributed Aboriginal cultural advice about the intervention
components. BB critically reviewed the paper and contributed to the design
of intervention components. All authors read and approved the final
manuscript.
Ethics approval and consent to participate
Not applicable for the design aspects of this study.
Consent for publication
Not applicable.
Competing interests
YBZ has received fees for lectures in the past (years 2012–2015) from
Novartis NCH (distributes NRT in Israel). She has not received any fees from
pharmaceutical companies in Australia. No other authors have competing
interests to declare.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
School of Medicine and Public Health, University of Newcastle, University
Drive, Callaghan, NSW 2308, Australia.
2
University College London, 1-19
Torrington Place, London WC1E 7HB, UK.
3
Clarence Specialist Clinic, 86
Through Street, South Grafton, NSW 2460, Australia.
Received: 13 July 2017 Accepted: 7 September 2017
References
1. Nilsen P. Making sense of implementation theories, models and frameworks.
Implement Sci. 2015;10:53.
2. Gould GS, Patten C, Glover M, Kira A, Jayasinghe H. Smoking in pregnancy
among Indigenous women in high-income countries: a narrative review.
Nicotine Tob Res. 2017;19:506–17.
3. Australian Institute of Health and Welfare. Australia’s mothers and babies
2014—in brief. Perinatal statistics series no. 32. Cat no. PER 87. Canberra:
AIHW; 2016.
4. Gould GS. Exploring the barriers and enablers to smoking cessation in
pregnant Aboriginal and Torres Strait Islander women with the Behaviour
Change Wheel. Australasian Epidemiologist. 2014;21:31–5.
5. Chamberlain C, O’Mara-Eves A, Porter J, Coleman T, Perlen SM, Thomas J,
McKenzie JE. Psychosocial interventions for supporting women to stop
smoking in pregnancy. Cochrane Database Syst Rev. 2017;2:
CD001055.
6. Nicholson AK, Borland R, Davey ME, Stevens M, Thomas DP. Predictors of
wanting to quit in a national sample of Aboriginal and Torres Strait Islander
smokers. Med J Aust. 2015;202:S26–32.
7. Nicholson AK, Borland R, Davey ME, Stevens M, Thomas DP. Past quit
attempts in a national sample of Aboriginal and Torres Strait Islander
smokers. Med J Aust. 2015;202:S20–5.
8. Bar-Zeev Y, Bonevski B, Twyman L, Watt K, Atkins L, Palazzi K, Oldmeadow C,
Gould GS. Opportunities missed: a cross-sectional survey of the provision of
smoking cessation care to pregnant women by Australian general
practitioners and obstetricians. Nic & Tob Res. 2017;19:636–41.
9. Okoli CTC, Greaves L, Bottorff JL, Marcellus LM. Health care providers’
engagement in smoking cessation with pregnant smokers. J Obstet
Gynecol Neonatal Nurs. 2010;39:64–77.
Gould et al. Implementation Science (2017) 12:114 Page 12 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

10. Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, Spiegelhalter D,
Tyrer P. Framework for design and evaluation of complex interventions to
improve health. BMJ. 2000;321:694–6.
11. Michie S, Atkins L, West R. The Behaviour Change Wheel—a guide to
designing interventions. Great Britain: Silverback; 2014.
12. Passey ME, Bryant J, Hall AE, Sanson-Fisher RW. How will we close in smoking
rates for pregnant Indigenous women. Med J Aust. 2013;199:39–41.
13. Stead LF, Lancaster T: Behavioural interventions as adjuncts to
pharmacotherapy for smoking cessation. Cochrane Database Syst Rev.2012
Issue 12 Art No: CD009670.
14. Coleman T, Chamberlain C, Davey MA, Cooper SE, Leonardi-Bee J:
Pharmacological interventions for promoting smoking cessation during
pregnancy. Cochrane Database Syst Rev, Issue 12 Art No: CD010078 2015.
15. Eades SJ, Sanson-Fisher RW, Wenitong M, Panaretto K, D’Este C, Gilligan C,
Stewart J. An intensive smoking intervention for pregnant Aboriginal and
Torres Strait Islander women: a randomised controlled trial. Med J Aust.
2012;197:42–6.
16. Patten CA, Windsor RA, Renner CC, Enoch C, Hochreiter A, Nevak C, Smith
CA, Decker PA, Bonnema S, Hughes CA, Brockman T. Feasibility of a tobacco
cessation intervention for pregnant Alaska Native women. Nicotine Tob Res.
2010;12:79–87.
17. Patten CA. Tobacco cessation intervention during pregnancy among Alaska
Native women. J Cancer Educ. 2012;27:S86–90.
18. Bar Zeev Y, Bovill M, Gruppetta M, Bonevski B, Gould GS. Assessing and
validating an educational resource package for the management of
smoking cessation in Indigenous pregnant women. Asia-Pacific J Clin Oncol.
2016;12:11.
19. Bovill M, Bar-Zeev Y, Gruppetta M, O’Mara P, Cowling B, Gould GS. Collective and
negotiated design for a clinical trial addressing smoking cessation supports for
Aboriginal and Torres Strait Islander mothers in NSW, SA and Qld? Developing a
pilot study. Aust J Prim Health. 2017. doi:10.1071/PY16140. [Epub ahead of print].
20. Michie S, van Stralen MM, West R. The Behaviour Change Wheel: a new
method for characterising and designing behaviour change interventions.
Implement Sci. 2011;6:42.
21. Cane J, O’Connor D, Michie S. Validation of the Theoretical Domains
Framework for use in behaviour change and implementation research.
Implement Sci. 2012;7:37.
22. Alexander KE, Brijnath B, Mazza D. Barriers and enablers to delivery of the
healthy kids check: an analysis informed by the Theoretical Domains
Framework and COM-B model. Implement Sci. 2014;9:60.
23. French SD, Green SE, O’Connor DA, McKenzie JE, Francis JJ, Michie S,
Buchbinder R, Schattner P, Spike N, Grimshaw JM. Developing theory-
informed behaviour change interventions to implement evidence into
practice: a systematic approach using the Theoretical Domains Framework.
Implement Sci. 2012;7:38.
24. Barker F, Atkins L, de Lusignan S. Applying the COM-B behaviour model and
Behaviour Change Wheel to develop an intervention to improve hearing-
aid use in adult auditory rehabilitation. Int J Audiol. 2016;55(Suppl 3):S90–8.
25. McSharry J, Murphy PJ, Byrne M. Implementing international sexual
counselling guidelines in hospital cardiac rehabilitation: development of the
CHARMS intervention using the Behaviour Change Wheel. Implement Sci.
2016;11:134.
26. Sinnott C, Mercer SW, Payne RA, Duerden M, Bradley CP, Byrne M.
Improving medication management in multimorbidity: development of the
MultimorbiditY COllaborative Medication Review And DEcision Making (MY
COMRADE) intervention using the Behaviour Change Wheel. Implement Sci.
2015;10:132.
27. Murphy AL, Gardner DM, Kutcher SP, Martin-Misener R. A theory-informed
approach to mental health care capacity building for pharmacists. Int J
Ment Heal Syst. 2014;8:46.
28. Westland H, Bos-Touwen ID, Trappenburg JCA, Schröder CD, de Wit NJ,
Schuurmans MJ. Unravelling effectiveness of a nurse-led behaviour change
intervention to enhance physical activity in patients at risk for
cardiovascular disease in primary care: study protocol for a cluster
randomised controlled trial. Trials. 2017;18:79.
29. Fulton EA, Brown KE, Kwah KL, Wild S. StopApp: using the Behaviour
Change Wheel to develop an app to increase uptake and attendance at
NHS stop smoking services. Healthcare (Basel). 2016;4(2)E31.
30. Tombor I, Shahab L, Brown J, Crane D, Michie S, West R. Development of
SmokeFree Baby: a smoking cessation smartphone app for pregnant
smokers. Transl Behav Med. 2016;6:533–45.
31. Gould GS, Watt K, Stevenson L, McEwen A, Cadet-James Y, Clough AR.
Developing anti-tobacco messages for Australian Aboriginal and Torres Strait
Islander peoples: evidence from a national cross-sectional survey. BMC Public
Health. 2014;14:250.
32. Baxter S, Everson-Hock E, Messina J, Guillaume L, Burrows J, Goyder E.
Factors relating to the uptake of interventions for smoking cessation
among pregnant women: a systematic review and qualitative synthesis.
Nicotine Tob Res. 2010;12:685–94.
33. Gould GS, Munn J, Watters T, McEwen A, Clough AR. Knowledge and views
about maternal tobacco smoking and barriers for cessation in Aboriginal
and Torres Strait Islanders: a systematic review and meta-ethnography.
Nicotine Tob Res. 2013;15:863–74.
34. Gould GS, McEwen A, Munn J. Jumping the hurdles for smoking
cessation in Indigenous pregnant women in Australia. J Smok Cessat.
2011;6:33–6.
35. Gould GS, Cadet-James Y, Clough AR. Getting over the shock: taking action
on Indigenous maternal smoking. Aust J Prim Health. 2016;22:276–82.
36. Passey M, D’Este CA, Sanson-Fisher R. Knowledge, attitudes and other
factors associated with assessment of tobacco smoking among pregnant
Aboriginal women by health care providers: a cross-sectional survey. BMC
Public Health. 2012;12
37. Passey M, Sanson-Fisher R, Gale J, Stirling J. Tobacco, alcohol and cannabis
use during pregnancy: views of pregnant Aboriginal women in NSW and
ACT. Lismore: University Centre for Rural Health-North Coast, University of
Sydney; 2011.
38. Passey M, Sanson-Fisher RW. Provision of antenatal smoking cessation
support: a survey with pregnant Aboriginal and Torres Strait Islander
women. Nicotine Tob Res. 2015;17(6):746–9.
39. Passey ME, Sanson-Fisher RW, Stirling JM. Supporting pregnant Aboriginal
and Torres Strait Islande r women to quit smoking: view s of antenatal
care providers and pregnant Indigenous women. Matern Child Health J.
2014;18:2293–9.
40. Tzelepis F, Daly J, Dowe S, Bourke A, Gillham K, Freund M. Supporting
Aboriginal women to quit smoking: antenatal and postnatal care providers’
confidence, attitudes, and practices. Nicotine Tob Res. 2017;19:642–6.
41. Bovill M, Gruppetta M, Cadet-James Y, Clarke M, Bonevski B, Gould GS.
Wula (voices) of Aboriginal women on barriers to accepting smoking
cessation support during pregnancy: findings from a qualitative study.
Women Birth. 2017. pii: S1871-5192(17)30086-0. doi:10.1016/j.wombi.
2017.06.006. [Epub ahead of print].
42. Gould GS, Bovill M, Clarke MJ, Gruppetta M, Cadet-James Y, Bonevski B.
Chronological narratives from smoking initiation through to pregnancy of
Indigenous Australian women: a qualitative study. Midwifery. 2017;52:27–33.
43. Gould GS, Bittoun R, Clarke MJ. A pragmatic guide for smoking
cessation counselling and the initiation of nicotine replacement therapy
for pregnant Aboriginal and Torres Strait Islander smokers. J Smok
Cessat. 2015;10:96–105.
44. Gould GS, Munn J, Avuri S, Hoff S, Cadet-James Y, McEwen A, Clough AR.
“Nobody smokes in the house if there’s a new baby in it”: Aboriginal
perspectives on tobacco smoking in pregnancy and in the household in
regional NSW Australia. Women Birth. 2013;26:246–53.
45. Mendelsohn C, Gould G, Oncken C. Management of smoking in pregnant
women. Aust Fam Physician. 2014;43:46–51.
46. Passey M, D’Este CA, Stirling JM, Sanson-Fisher RW. Factors associated with
antenatal smoking among Aboriginal and Torres Strait Islander women in
two jurisdictions. Drug Alcohol Rev. 2012;31:608–16.
47. Gould GS. Here’s how to close the gap on Indigenous women smoking
during pregnancy. The Conversation. 2016;(Iss. July 21). Accessed 14 Sept
2017 from http://theconversation.com/heres-how-toclose-the-gap-on-
indigenous-women-smoking-during-pregnancy-62347.
48. Heath DL, Panaretto K, Manessis V, Larkins S, Malouf P, Reilly E, Elston J. Factors to
consider in smoking interventions for Indigenous women. Aust J Prim Health.
2006;12:131–6.
49. Carson K, Jayasinghe H, Smith B, Newchurch J, Brinn M, Veale A, Peters M,
Esterman A, Singh K. Thoracic Society of Australia and New Zealand.
Smoking cessation and tobacco prevention in Indigenous populations.
Evidence Base, Australia and New Zealand School of Government. 2015.
Accessed 14 Sep 2017. from http://apo.org.au/node/52346.
50. Zwar N, Richmond R, Borland R, Peters M, Litt J, Bell J, Caldwell B, Ferretter I:
Supporting smoking cessation: a guide for health professionals Melbourne: the
Royal Australian College of General Practitioners; 2011 [Updated July 2014].
Gould et al. Implementation Science (2017) 12:114 Page 13 of 14
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

51. Twyman L, Bonevski B, Paul C, Bryant J. Perceived barriers to smoking
cessation in selected vulnerable groups: a systematic review of the
qualitative and quantitative literature. BMJ Open. 2014;4:12.
52. Ministry of Health. Implementing the ABC approach for smoking cessation:
framework and work programme. Wellington, New Zealand: Ministry of
Health; 2009.
53. Patwardhan PD, Chewning BA. Ask, advise and refer: hypothesis generation
to promote a brief tobacco-cessation intervention in community
pharmacies. Int J Pharm Pract. 2009;17:221–9.
54. Gould G, McEwen A. An intensive smoking intervention for pregnant
Aboriginal and Torres Strait Islander women: a randomised controlled
trial—letter. Med J Aust. 2013;198:23.
55. Carson KV, Verbiest MEA, Crone MR, Brinn MP, Esterman AJ, Assendelft WJJ,
Smith BJ. Training health professionals in smoking cessation. Cochrane
Database Syst Rev. 2012;5:CD000214.
56. Bar-Zeev Y, Bovill M, Gould GS. Indigenous Counselling and Nicotine (ICAN)
Quit in Pregnancy educational resource package. Callaghan: University of
Newcastle; 2016.
57. Michie S, Richardson M, Johnston M, Abraham C, Francis J, Hardeman W,
Eccles MP, Cane J, Wood CE. The behavior change technique taxonomy (v1)
of 93 hierarchically clustered techniques: building an international
consensus for the reporting of behavior change interventions. Ann Behav
Med. 2013;46:81–95.
58. Bar-ZeevY,BonevskiB,BovillM,GruppettaM,OldmeadowC,PalazziK,
Atkins L, Reath J, Gould GS, ICAN QUIT in Pregnancy Pilot Group. The
Indigenous Counselling and Nicotine (ICAN) QUIT in Pregnancy pilot
study protocol: a feasibility step-wedge cluster rando mized trial to
improve health providers management of smoking during pregn ancy.
BMJ Open. 2017;7(8):e016095.
59. Resnicow K, Soler R, Braithwaite RL, Ahluwalia JS, Butler J. Cultural sensitivity
in substance use prevention. J Community Psychol. 2000;28:271–90.
60. Gilligan C. Aboriginal and Torres Strait islander women: an examination of
smoking during pregnancy. Newcastle: University of Newcastle; 2008.
61. Boucher J, Konkle AT. Understanding inequalities of maternal
smoking—bridging the gap with adapted intervention strategies. Int J
Environ Res Public Health. 2016;13:3.
62. Flemming K, Graham H, McCaughan D, Angus K, Sinclair L, Bauld L. Health
professionals’perceptions of the barriers and facilitators to providing
smoking cessation advice to women in pregnancy and during the post-
partum period: a systematic review of qualitative research. BMC Public
Health. 2016;16:290.
63. Flemming K, McCaughan D, Angus K, Graham H. Qualitative systematic
review: barriers and facilitators to smoking cessation experienced by women in
pregnancy and following childbirth. J Adv Nurs. 2015;71(6)1210–26.
64. Lorencatto F, West R, Michie S. Specifying evidence-based behavior change
techniques to aid smoking cessation in pregnancy. Nicotine Tob Res.
2012;14:1019–26.
65. Atkins L, Michie S. Designing interventions to change eating behaviours.
Proc Nutr Soc. 2015;74:164–70.
66. Bar-Zeev Y, Bovill M, Bonevski B, Gould G. Indigenous counselling and
nicotine (ICAN) QUIT in pregnancy—developing an evidence-based
intervention for smoking cessation for Indigenous pregnant women. Asia
Pac J Clin Oncol. 2015;11:9.
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