This poster was presented at the 45th Union World Conference on Lung Health in 2014. It outlines the interim findings of a study that tests behaviour change interventions aimed at lung health patients in Nepal

1. 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.