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.
The study used a combination of qualitative methods SETTING
USE OF BEHAVIOUR CHANGE TECHNIQUES
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.

Evidence Review

Phase 1
21 qualitative Interviews with
lung health patients and FGDs
with PHC staff
Phase 2

Intervention development
workshop

Action Research & Baseline

Fagerstrom and CO

The intervention was tested in 3 primary health care centres (PHCCs)

selected based on sufficient patient flow, training of staff in WHOs
Practical Approach to Lung Health. 2 PHCCs were in a rural location in
the Terai plains and 1 PHCC was in urban Kathmandu.

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.

The intervention drew on Michie et als (4) identified behaviour change

techniques (BCTs), as illustrated on the Quit Card shown below..
BCT 4 &10 : prompt
specific goal setting
by setting quit day.

BCT 6 : provide general

encouragement for self
efficacy and motivation

Quit Card showing use of

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

Materials include:
Posters on the dangers of smoking and
chewing tobacco
BCT 5: identifying
Phase 3
barriers and coping
Follow up at 3 months
Poster
advertising
the
smoking
cessation
Fine-tune intervention
Fagerstrom and CO monitors
strategies to build
service in primary health clinics
self efficacy and
Leaflets for patients on the dangers of
skills to overcome
ACTION RESEARCH
smoking and chewing tobacco
barriers
To understand the barriers and facilitators to implementation
Flip book to be used by health workers in a
BCT 24: Keeping
in primary care, researchers facilitated action research
motivation by
meetings with the health workers in the 3 PHCCs. The groups brief counselling session
identifying and
Quit card to support abstinence
reflected on the implementation process and tried different
recording why
strategies to overcome any challenges over a 3 month period. DVD is under development
they want to quit.
Key Findings from the Action Research
FOLLOW UP RESULTS
Patient Flow through
1) Intervention for all patients: Initially the intervention was
It was only possible to trace a total of 27 patients out of the 44
the Intervention
planned for respiratory patients only. However, health
who had received the counselling from the health worker. All
workers in all 3 PHCCs were adamant that the intervention
patients provided a CO sample, completed a questionnaire and
should be made available to all patients. The materials
provided feedback on the different aspects of the intervention and
were changed to include risk of tobacco use to cardiotheir experience of trying to quit. Patients were defined as having
vascular health and during pregnancy. The intervention
quit if they had a CO reading of 9 ppm and had smoked no more
was then offered to all patients in OPD.
than 5 cigarettes since their quit day.
2) Identifying smokers: Although health workers were keen
Urban PHCC Rural PHCC 1 Rural PHCC 2 Total
to open the intervention to all patients, in reality this was
challenging to implement due to the high patient numbers
4416
5062
2852
12330
Total out patients
particularly in clinics for reproductive and child health.
over 3 month
period
Patients were reluctant to admit to smoking when asked
Smokers identified 56 (1.3%)
29 (0.6%)
19 (0.7%)
104 (0.8%)
by the health worker. The overcrowded consultation room
QUALITATIVE FINDINGS
(as a % of total out
and manner of the health worker were identified as
patients)
undermining patients willingness to admit their habit. To
Smokers receiving 13 (23.2%) 18 (62.1%)
13 (68.4%)
44 (42.3%)
overcome this the team tried the use of volunteers to
counselling (as a %
sensitise communities of the availability of the cessation
of identified
programme and the use of PHCC support staff to
smokers)
encourage patients to be open. However limited numbers
Those. traced at 3 5 (38.5%)
12 (66.7%)
10 (76.9%)
27 (61.4%)
of smokers were identified, particularly as a proportion of
months follow up
all out patients in the PHCCs.
(as a % of those
counselled)
3) Recording and reporting: The main register in the PHCCs
Smokers who quit 1 (20%)
5 (41.7%)
4 (40%)
10 (37%)
did not have space to record smoking status. As these
(as a % of those
PHCCs were implementing WHOs PAL approach, the PAL
counselled)
register was used to record smoking, however health
workers did not fully understand the categories or
Feedback on the Intervention
Fagerstrom assessment tool in the PAL register as this was
The majority of patients (74%) were satisfied by the health workers
in English and had not been covered in depth in their PAL
support during counselling. Where patients complained about their
training. The researchers supported the health workers in
interaction with the health worker, they lost motivation to quit.
this aspect. The Government of Nepal now plans to
including smoking status in the main PHCC register.
The majority of patients, particularly those with low literacy levels,
did not find the quit card useful and had lost their card.
4) High use of Smokeless Tobacco: the original intervention
materials did not include chewing tobacco. Given the high
While two patients reported that they had stopped chewing tobacco,
prevalence in the two Terai PHCCs, warnings of the
three admitted taking up chewing to substitute cigarettes.
dangers of chewing tobacco were added to the materials.
Patients preferred graphic pictures and photographs of the physical damage caused by smoking or
5) Motivation of Health Workers: only a few health workers were motivated to deliver the
chewing tobacco.
intervention. As the intervention was not seen as a part of core activities and was not a
Confusion over Not a puff message: Many patients had managed to reduce the number of cigarettes
performance indicator for the PHCC, the health workers did not prioritise the intervention.
smoked, but had not appreciated the need to identify a quit day and not smoke again.
This lack of motivation impacted on the number of identified and counselled and the quality
The most common barrier to quitting identified was being encouraged to smoke by friends. Conversely,
of the counselling provided. Establishing smoking cessation as a core, routine service with
when families were supportive, this was a facilitator to quitting.
monitoring from central and district health departments is needed to essential for the
effective and sustainable implementation of the programme.
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, 20122022.
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), 660680
, 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

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.