Nepal has the highest rates of tobacco use in South Asia. While increasing focus is being placed on raising awareness about the dangers of tobacco use, there are currently no programmes to support people who already use tobacco to quit effectively. Our study recommends integrating tobacco cessation support into the regular health care system to help existing smokers to quit.
1. Action is required across the health care system to enable health care workers within Primary Health Care Centres (PHCCs) to prioritise support to patients to quit tobacco use.
2. Indicators on tobacco use should be integrated into the regular Health Management Information System (HMIS) for better reporting and recording among all outpatients and not only the lung health patients.
3. The Practical Approach to Lung Health (PAL) register should be translated to Nepali for all PHCCs.
4. There is a need for clarification on how to categorise patients on the PAL register
5. Scaling up of behavioural and counselling support for lung health patients to include outpatient departments (OPDs) would increase the impact of smoking cessation interventions.
6. Tobacco control interventions should address the use of smokeless, or chewing tobacco.
7. Scaling up and disseminating the information, education and communication (IEC) materials to all PHCCs e.g. flipbooks, posters and leaflets is essential for delivering consistent information in a structured way and raising awareness amongst the patients.
8. Addressing the motivation of health workers is essential for the effective delivery of tobacco cessation interventions at PHCCs.
Nepal has the highest rates of tobacco use in South Asia, with 30% of men and 9% of women smoking cigarettes and 38% of men and 6% of women using other forms of tobacco. Tobacco use is a growing challenge and a public health concern in Nepal. It increases the risk of various communicable and non-communicable diseases like TB, chronic respiratory conditions, cardiovascular disease and cancers, and it contributes to morbidity and mortality.
Our study builds on the successful implementation of the ASSIST trial that showed high quit rates with 41% able to quit following brief behaviour change support to patients with suspected TB. We assessed the feasibility of a behaviour change intervention within
the Practical Approach to Lung Health (PAL) programme in Primary Health Care Centres (PHCCs) in 2 districts of Nepal: Kathmandu and Rupandehi.
Our intervention package
Our intervention includes using a health care worker at the PHCC to deliver counselling to lung health patients who smoke. This counselling support by the health care workers employed behaviour change techniques, addressing factors such as maintaining willpower and motivation to give up smoking. During the counselling, health workers used information education and communication (IEC) materials such as flipbooks and leaflets.
We also produced a flowchart (figure 1) of the process to help health care workers remember the steps of the intervention. This flowchart covers all the options available to health care workers and patients in a structured way.
Key findings about the existing tobacco control scenario:
1. There is a demand from communities for support in quitting tobacco and health care workers were seen as potentially effective providers of this service.
2. Smoking cessation, though a part of the PAL programme, is not emphasised enough in the regular health care system. There is a need for effective supervision and monitoring
from the central and district level authorities for effective implementation of the PAL programme.
3. Recording and reporting for PAL, and details of patients’ smoking status, was found to be irregular and incomplete. The PAL reporting system is an additional requirement to
the regular Health Management Information System (HMIS) reporting system.
4. The PAL register being printed in English is one of the major reasons for health care workers not completing the register due to difficulties understanding the English language. Our translated Nepali versions proved to be more effective and convenient for health care workers.
5. Health care workers found categorising patients on the PAL register confusing. Categorising patients as ‘current smokers’ if they quit less than 4 weeks ago, and as ‘old
smokers’ if they quit more than 4 weeks ago, was found to be more effective in this study
- Action is required across the health care system to enable health care workers within PHCCs to prioritise support to patients to quit tobacco use. Specific actions could include:
- developing guidelines, training and materials to deliver effective tobacco cessation support by health care workers; and
- regular monitoring and supervision from central and district level authorities.
- Indicators on tobacco use should be integrated into the regular Health Management Information System (HMIS) for better reporting and recording among all outpatients and not only the lung health patients.
- The PAL register should be translated into Nepali for all PHCCs.
- There is a need for clarification on how to categorise patients on the PAL register.
Key findings about our intervention package:
1. While the numbers in this study were small (44), we found that 37% of smokers who received the behavioural support intervention were able to quit smoking.
2. Chewing tobacco is often a substitute for cigarettes.
3. The flipbook makes the health worker counselling session with the patients more
structured and effective; the leaflet and poster, as well as providing information, also
serve as good reminders for patients.
- Scaling up of behavioural and counselling support for lung health patients to include OPDs would increase the impact of smoking cessation interventions.
- Tobacco control interventions should address the use of smokeless, or chewing, tobacco.
- Scaling up and disseminating the IEC materials to all PHCCs – e.g. flipbooks, posters and leaflets – is essential for delivering consistent information in a structured way and raising awareness amongst the patients.
Key findings for health service delivery:
1. Health workers felt overworked to take part in the behavioural and counselling support
sessions with patients, and lacked motivation to deliver the intervention.
2. Absence of health workers at the PHCCs due to their other engagements often
resulted in patients not getting the intervention at the health facility they visited. This poses a challenge for implementing the behavioural and counselling support sessions effectively
- Addressing the motivation of health workers is essential for effective delivery of tobacco cessation interventions at PHCCs
Based on the existing evidence and findings from our qualitative study, we developed a behaviour change intervention package by:
- implementing the intervention in 3 PHCCs; 2 in Rupandehi district and 1 in Kathmandu district
- refining the intervention to make it locally appropriate using action research methods
- testing the refined intervention in the 3 study PHCCs
- conducting follow-up interviews of thepatients involved in the intervention after 3 months. We used a carbon monoxide monitor to validate their smoking status.
With the growing trend of tobacco use in Nepal, behaviour change interventions that can be delivered in PHCCs could be an effective way of helping tobacco users to quit.
Sushil Baral, Sudeepa Khanal, Shraddha Manandhar and Dilip Sah, HERD Nepal;
Helen Elsey, COMDIS-HSD.
- Ministry of Health and Population. (2011) Nepal Demographic and Health Survey 2011. Kathmandu, MHP
- Siddiqi K, Khan A, Ahmad M, Dogar O, Kanaan M, Newell J, Thomson H. (2013) Action to stop smoking in suspected tuberculosis (ASSIST) in Pakistan. Annals of Internal Medicine. 158(9): 667-675. doi:10.7326/0003-4819-158-9-201305070-00006
For more information about the research, please email Sudeepa Khanal, Senior Manager, HERD at: firstname.lastname@example.org
This project was funded by UK aid from the UK government.