Developing and Implementing a Smoking Cessation Intervention in Primary Care in Nepal

Sushil Baral ;Sudeepa Khanal; Shraddha Manandar; Dilip Kumar Sah; Kamran Siddiqi; Helen Elsey

BACKGROUND Prevalence of tobacco among those over 15 years is estimated to be 31.6% overall, 52% among men and 13% among women. Use of smokeless tobacco is also high, particularly chewing tobacco, with 38% of men and 6% of women using this form of tobacco (1). Despite this high smoking prevalence there are no smoking cessation services in routine primary care. Respiratory conditions are one of the most common reasons for presenting at primary care with 17.1% of male patients and 11.3% of female patients having a respiratory condition (2). There is evidence of effectiveness and cost-effectiveness of number of psychological and pharmacological treatments for tobacco dependence, particularly where advice is given by trained health professionals (3)

Aim: To develop and test the feasibility of a behavioural support intervention to promote smoking cessation within the in primary care in Nepal.

METHODS The study used a combination of qualitative methods and action research to understand the barriers and facilitators to implementation. Patients receiving the intervention were followed up over a 3 month period to gain their feedback on the intervention and to identify those who had quit.

USE OF BEHAVIOUR CHANGE TECHNIQUES

The intervention drew on Michie et al’s (4) identified behaviour change techniques (BCTs), as illustrated on the Quit Card shown below..

FOLLOW UP RESULTS

It was only possible to trace a total of 27 patients out of the 44 who had received the counselling from the health worker. All patients provided a CO sample, completed a questionnaire and provided feedback on the different aspects of the intervention and their experience of trying to quit. Patients were defined as having quit if they had a CO reading of ≤ 9 ppm and had smoked no more than 5 cigarettes since their quit day.

ACTION RESEARCH

To understand the barriers and facilitators to implementation in primary care, researchers facilitated action research meetings with the health workers in the 3 PHCCs. The groups reflected on the implementation process and tried different strategies to overcome any challenges over a 3 month period.

Key Findings from the Action Research

1) Intervention for all patients: Initially the intervention was planned for respiratory patients only. However, health workers in all 3 PHCCs were adamant that the intervention should be made available to all patients. The materials were changed to include risk of tobacco use to cardio-vascular health and during pregnancy. The intervention was then offered to all patients in OPD.

2) Identifying smokers: Although health workers were keen to open the intervention to all patients, in reality this was challenging to implement due to the high patient numbers particularly in clinics for reproductive and child health. Patients were reluctant to admit to smoking when asked by the health worker. The overcrowded consultation room and manner of the health worker were identified as undermining patients’ willingness to admit their habit. To overcome this the team tried the use of volunteers to sensitise communities of the availability of the cessation programme and the use of PHCC support staff to encourage patients to be open. However limited numbers of smokers were identified, particularly as a proportion of all out patients in the PHCCs.

3) Recording and reporting: The main register in the PHCCs did not have space to record smoking status. As these PHCCs were implementing WHO’s PAL approach, the PAL register was used to record smoking, however health workers did not fully understand the categories or Fagerstrom assessment tool in the PAL register as this was in English and had not been covered in depth in their PAL training. The researchers supported the health workers in this aspect. The Government of Nepal now plans to including smoking status in the main PHCC register.

4) High use of Smokeless Tobacco: the original intervention materials did not include chewing tobacco. Given the high prevalence in the two Terai PHCCs, warnings of the dangers of chewing tobacco were added to the materials.

QUALITATIVE FINDINGS

CONCLUSIONS

The study demonstrates that it is feasible to implement a smoking cessation intervention in primary care, particularly if the intervention is target at those patients who are motivated to quit. The patients who received the counselling felt the intervention helped them to quit.

Greater attention to the ‘not a puff’ rule was needed in the training and subsequent patient counselling sessions. In areas with high prevalence of smokeless tobacco, particular attention is needed within the intervention to ensure that quitters do not take up chewing tobacco to compensate for cigarettes.

A limitation of the study is the low number of smokers identified and receiving the intervention. This means that conclusions about effectiveness can not be drawn from this small sample.

Embedding smoking cessation within routine primary care is key to successful delivery. This requires effective reporting and supervision mechanisms within the health system.

Please be in touch: Helen Elsey (University of Leeds) h.elsey@leeds.ac.uk Sudeepa Khanal (Health Research and Social Development Forum, HERD, Nepal) sudeepa.khanal@herd.org.np

REFERENCES 1. Ministry of Health and Population (2012) Nepal Demographic and Health Survey 2011 Population DivisionGovernment of Nepal, New ERA Nepal and ICF International, U.S.A 2.WHO (2008) Report on the Global Tobacco Epidemic, 2008:. Geneva, World Health Organization, 2008.

3. Gorin SS & Heck JE (2004) Meta-analysis of the efficacy of tobacco counselling by health care providers. Cancer Epidemiology and Biomarkers Preventions 13, 2012–2022. 4.Michie et al (2008) From Theory to Intervention: Mapping Theoretically Derived Behavioural Determinants to Behaviour Change Techniques Applied psychology: an international review, 2008, 57 (4), 660–680 ,

Phase 3

Fine-tune intervention Follow up at 3 months

Fagerstrom and CO monitors

Phase 2

Intervention development workshop

Action Research & Baseline Fagerstrom and CO

Phase 1

Evidence Review 21 qualitative Interviews with lung health patients and FGDs

with PHC staff

INTERVENTION Intervention design drew on initial ;qualitative work with smokers with respiratory conditions and focus groups with health workers. Ministry of Health and Population staff participated in a design workshop and ultimately endorsed all materials. Training was provided to all the health workers in their facilities.

BCT 24: Keeping motivation by identifying and recording why they want to quit.

BCT 5: identifying barriers and coping strategies to build self efficacy and skills to overcome barriers

BCT 6 : provide general encouragement for self efficacy and motivation

BCT 12 : prompt self monitoring behaviour by ticking days quit.

BCT 4 &10 : prompt specific goal setting by setting quit day.

Patient Flow through the Intervention

Materials include:

•Posters on the dangers of smoking and chewing tobacco

•Poster advertising the smoking cessation service in primary health clinics

•Leaflets for patients on the dangers of smoking and chewing tobacco

•Flip book to be used by health workers in a brief counselling session

•Quit card to support abstinence

•DVD is under development

SETTING The intervention was tested in 3 primary health care centres (PHCCs) selected based on sufficient patient flow, training of staff in WHO’s Practical Approach to Lung Health. 2 PHCCs were in a rural location in the Terai plains and 1 PHCC was in urban Kathmandu. Quit Card showing use of

Behaviour Change Techniques

5) Motivation of Health Workers: only a few health workers were motivated to deliver the intervention. As the intervention was not seen as a part of core activities and was not a performance indicator for the PHCC, the health workers did not prioritise the intervention. This lack of motivation impacted on the number of identified and counselled and the quality of the counselling provided. Establishing smoking cessation as a core, routine service with monitoring from central and district health departments is needed to essential for the effective and sustainable implementation of the programme.

Urban PHCC

Rural PHCC 1 Rural PHCC 2 Total

Total out patients over 3 month period

4416 5062 2852 12330

Smokers identified (as a % of total out patients)

56 (1.3%) 29 (0.6%) 19 (0.7%) 104 (0.8%)

Smokers receiving counselling (as a % of identified smokers)

13 (23.2%) 18 (62.1%) 13 (68.4%) 44 (42.3%)

Those. traced at 3 months follow up (as a % of those counselled)

5 (38.5%) 12 (66.7%) 10 (76.9%) 27 (61.4%)

Smokers who quit (as a % of those counselled)

1 (20%) 5 (41.7%) 4 (40%) 10 (37%)

Feedback on the Intervention

The majority of patients (74%) were satisfied by the health workers support during counselling. Where patients complained about their interaction with the health worker, they lost motivation to quit.

The majority of patients, particularly those with low literacy levels, did not find the quit card useful and had lost their card.

While two patients reported that they had stopped chewing tobacco, three admitted taking up chewing to substitute cigarettes.

Patients preferred graphic pictures and photographs of the physical damage caused by smoking or chewing tobacco.

Confusion over ‘Not a puff’ message: Many patients had managed to reduce the number of cigarettes smoked, but had not appreciated the need to identify a quit day and not smoke again.

The most common barrier to quitting identified was being encouraged to smoke by friends. Conversely, when families were supportive, this was a facilitator to quitting.