ARTICLE IN PRESS

0277-9536/$ - se

doi:10.1016/j.so

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(H141251011)

Health Policy, b

Unit, Universit

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Social Science & Medicine 63 (2006) 1546–1549

www.elsevier.com/locate/socscimed

Short report

Young mothers and smoking: evidence of an evidence gap$

Elizabeth McDermotta,�, Hilary Grahamb

aLancaster University Lancaster, UKbThe University of York, UK

Available online 26 May 2006

Abstract

The contribution of qualitative research to the development of public health policy is increasingly recognised, with

systematic reviews established as the methodology of choice for mapping and assessing evidence. Identifying research gaps

is an essential part of the review process, and is integral to developing a sound evidence base for policy. The paper reports

on a planned systematic review of qualitative research on teenage mothers and smoking terminated because of such a gap.

The review raises questions about the narrow range of evidence on which smoking cessation interventions for this

disadvantaged group are based, with the paucity of information on young mothers’ experiences potentially limiting the

development of effective smoking cessation interventions for teenage mothers.

r 2006 Elsevier Ltd. All rights reserved.

Keywords: UK; Systematic review; Qualitative; Smoking; Teenage mothers

Introduction

The experiences of disadvantaged groups areincreasingly recognised to be an important part ofevidence-based public health policy (Department ofHealth, 1999; Harden & Oliver, 2001). In England,for example, the government is seeking to incorpo-rate the views of young people into the design anddelivery of its strategies to support teenage mothers(IAGTP, 2003). Qualitative research has a centralrole to play in such user-informed policies, provid-

e front matter r 2006 Elsevier Ltd. All rights reserved

cscimed.2006.03.025

r draws on research funded by the ESRC

through the Centre for Evidence-based Public

ased at the MRC Social & Public Health Services

y of Glasgow, UK. The Centre is part of the

ce Network.

ing author. Tel.: +44 01524 593701.

ess: e.mcdermott@lancaster.ac.uk

).

ing a set of rigorous methods through which healthexperiences can be accessed and mapped as aresource for policy (Social Exclusion Unit (SEU)(2004)).

However, qualitative research has only recentlybeen included in systematic reviews, held up as the‘gold standard’ methodology for generating evi-dence for policy (Dixon-Woods & Fitzpatrick,2001). Originally developed for quantitative studies,it specifies a set of procedures for identifyingstudies, appraising their quality and synthesisingfindings. A common outcome of the review processis an absence of evidence with such reviews tendingto be under-valued and therefore under-reported(Alderson & Roberts, 2000; Alderson, 2004). How-ever, reporting insufficient evidence and uncertainanswers are integral to the evidence-generatingprocess, particularly as a guide and stimulus forfuture research (Alderson & Roberts, 2000). Petti-

.

ARTICLE IN PRESSE. McDermott, H. Graham / Social Science & Medicine 63 (2006) 1546–1549 1547

grew (2003, pp. 758) states, ‘it is after all, only bymapping what is known and acknowledging un-certainty that scientific knowledge can cumulate’.

The paper reports on a planned systematic review(SR) which aimed to search, appraise and reviewqualitative studies of teenage mothers and smoking.Because of the focus on mothers’ subjectiveexperiences, quantitative studies were not included.We begin by outlining the review’s rationale beforedescribing the SR. The final section discusses theimplications of uncovering an absence of qualitativeresearch to interventions which seek to reducesmoking rates in young mothers.

Teenage mothers and smoking cessation interventions

Expectant mothers under the age of 20 reporthigh rates of pre-pregnancy smoking (Departmentof Health, 2002). Pregnancy, and first pregnancy inparticular, increases motivation to quit in all agesand socioeconomic groups and is the major focus ofsmoking cessation interventions for women (Penn &Owen, 2002). However, there are socioeconomicdifferentials in cessation, with the lowest ratesamong mothers experiencing multiple disadvantage(Hamlyn, Brooker, Oleinikova, & Wands, 2002). InEngland, targets set for reducing smoking preva-lence throughout pregnancy have therefore incor-porated a focus on disadvantaged smokers(Department of Health, 2003), and Sure Start,England’s early years programme centred on poormothers and children, includes a pilot programme(www.info.doh.gov.uk/tpu/tpu.nsf) aimed to reducethe numbers of teen mothers smoking during andafter pregnancy.

There is an important seam of qualitative studiesof smoking among poor mothers (of all ages)(Graham, 1993; Greaves, 1996; Stead, MacAskill,MacKintosh, Reece, & Eadie, 2001). A consistentfinding is that, while mothers are aware of thehealth risks to them and their children, theyexperience smoking as a vital resource for caringfor their children in circumstances marked bychronic disadvantage. What is not clear is whetherthese findings are generalisable to women whobecome pregnant in their teenage years. Withpolicies targeting this group of mothers, we set outto systematically review research on young mothers’perspectives on their smoking behaviour. Bothauthors are social scientists experienced in thesystematic review of qualitative evidence.

Systematic review

There are no set guidelines for systematicallyreviewing qualitative research. We therefore drewon international guidelines for systematic reviews(CRD, 2001) and strategies from the emergingqualitative SR literature (e.g. Rees et al., 2001;Dixon-Woods, Agarway, Jones, Young, & Sutton,2005). In addition to ‘conventional’ search strate-gies, we undertook snowball citation (Booth, 2001),hand searching of relevant edited book collections,and more iterative study-identification strategiessuch as networking with appropriate experts.

Search strategy

A preliminary scoping exercise suggested thatthere was a potential pool of international researchinvestigating young mothers’ experiences of smok-ing. A full search strategy was therefore designed tolocate published and unpublished research (searchesconducted between Feb. and Mar. 2003).

Search terms, developed in line with systematicreview practice, included terms for young mothers(e.g. adolescent*, teen*, mother*, maternity), smok-ing status (e.g. smok*, tobacco, nicotine, cigarette*)and qualitative methods (e.g. Case Stud*, Partici-pant Observ*, Ethnograph*, Focus Group*). Mind-ful of the difficulties associated with locatingqualitative evidence in electronic databases (Petti-crew and Roberts, 2006; Shaw et al., 2004), weoptimized our search strategy by adjusting searchterms to the structure of the databases and researchregisters. We used keywords, subheadings and meshterms which are used to categorise qualitativeresearch in databases, e.g. prior to 2003, Medlinehad used the MeSH heading ‘‘Nursing Methodol-ogy Research’’. We also used free-text terms such as‘qualitativ*’, and terms which may be specific todatabases or research registers.

Searches were conducted on core bibliographicdatabases (e.g. Medline, Assia, CINAHL), researchregisters (e.g. Cochrane database of systematicreviews), relevant websites (e.g. Joseph RowntreeFoundation) and grey literature gateways (e.g.SOSIG.ac.uk). In addition, a variety of internetsearch engines were employed, key informants inthe field were contacted and relevant edited books,theses, grey literature and journals were hand-searched (e.g. International Journal of AdolescentHealth) and the ‘snowball’ citation method utilised.

ARTICLE IN PRESSE. McDermott, H. Graham / Social Science & Medicine 63 (2006) 1546–15491548

The combined search strategies yielded 952citations. From the abstracts and titles, 913 citationswere excluded mainly because they were studieswhich were not qualitative (or mixed method),investigating smoking or involving teenage mothers.

Inclusion/exclusion criteria

The inclusion/exclusion criteria (Fig. 1) weredesigned to retain studies which specifically elicitedyoung mothers’ views about their smoking beha-viour. Studies were excluded if they did not reportyoung mothers’ accounts. The criteria were appliedto the 39 studies by two researchers independently.

Only two studies met the inclusion criteria: fromthe USA (Lawson, 1994) and Australia (Wakefield,Reid, Roberts, & Mullins, 1998). The review washalted at this point due to insufficient studies to be

Fig. 1. Inclusion/exc

synthesized. As a check on our evidence of evidencegap, we repeated the review process amending thepopulation and outcome criteria to exclude referenceto smoking status. For this review, we focused simplyon women under 20 who are pregnant or caring forX1 child and on studies concerned with theiraccounts of their lives. The second SR generated 10studies for review, none of which contained data onsmoking. The systematic review did however providethe basis for a qualitative synthesis of youngmothers’ experiences of parenting (Graham &McDermott, 2005; McDermott, Graham, & Hamil-ton, 2004; McDermott & Graham, 2005).

Discussion

Our review found very little qualitative evidenceexploring young mothers’ perspectives on their

lusion criteria.

ARTICLE IN PRESSE. McDermott, H. Graham / Social Science & Medicine 63 (2006) 1546–1549 1549

smoking behaviour. The problem of locatingqualitative literature has been widely reported(McDermott et al., 2004; Shaw et al., 2004). It istherefore possible that, like other qualitative re-views, our search strategies missed some relevantstudies. But potential weaknesses in the search areunlikely to explain the dearth of studies. Moreplausibly, the review suggests a key evidence gap—and therefore an area for future research.

The evidence gap raises questions about the typeof evidence on which policies addressing smokingamong young mothers is based. Grounded inquantitative research, interventions may fail torecognise—and therefore to address—the factorswhich make smoking a particularly difficult habit tobreak for this highly disadvantaged group ofwomen. In turn, the absence of qualitative evidence,and the understandings they could provide into thesubjectively experienced barriers to cessation, maybe limiting the development of effective smokingcessation interventions for young mothers. Addres-sing this evidence gap should be a priority for pubichealth research and policy.

Our review may also serve as a case study whichhighlights a wider gap in the qualitative evidencebase of public health policy. Both cigarette smokingand teenage mothers are high on the policy agenda,yet their intersection has yet to be a sustained focusof qualitative research. If this pattern is repeated forother priority groups, it suggests that contemporarypublic health policy lacks grounding in the experi-ences of those whose lifestyles it seeks to change.

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