This qualitative study of HCWs from six disadvantaged DR communities identified attitudes and practices that mitigate against implementation of smoking cessation interventions. Differences between MDs and other HCWs were few. Smoking among clients or in the community was not a priority concern for these DR HCWs. They expressed general opinions about smoking in their community that for the most part paralleled those expressed by community members (Dozier et al.
). Compared with earlier findings from these same communities (Dozier et al.
), HCWs were more informed about the negative health effects of smoking and the impact of passive smoking but their knowledge was incomplete (e.g. relationship between asthma and smoking). Of note, HCWs did not differentiate social smokers from more routine smokers (as the community did). While HCWs did not view their role in cessation as important, our earlier findings indicated that community members did. The latter specifically mentioned MDs as central to theses interventions, a finding consistent with the literature from other countries (Bremberg & Nilstun, 2005
). Despite community difference between tobacco and non-tobacco growing communities, a similar distinction was not found among the HCWs.
HCWs in these DR communities were not proactive vis a vis their role in tobacco cessation. Based on a model such as the 5 As brief intervention (ask, advise, assess, assist, arrange) (Fiore et al., 2000
), among these HCWs, assessment of smoking status or tobacco use (Asking) was not routine and interventions for primary prevention (to prevent tobacco initiation) were absent. Cessation discussions were limited in scope to providing information (Advising) and not based on guidelines or other evidence. Research from other countries identified factors that influenced initiation of cessation discussions: HCW tobacco use (current or former), patient demographics, patient smoking habits and patient condition (Bremberg & Nilstun; Block et al., 2000
; Ossip-Klein, et al.
; Varona, et al.
). Similar to Coleman et al.’s qualitative study (2000)
HCWs were most likely to discuss cessation with a patient who had a smoking related illness.
Another factor, not well described in the literature, may account for HCWs limited involvement with smoking cessation. These DR HCWs including the MDs held strong views that personal will was key to an individual’s cessation success. This belief may hinder HCWs from assuming a greater role in initiating cessation discussions or supporting quit attempts and represents a significant barrier to changing their practice. While not specifically described in earlier studies this belief may be similar to concerns among providers about the applicability and effectiveness of interventions with their patient population (Litaker et al.
). Few other barriers to implementing cessation interventions were identified by these DR HCWs. This differs dramatically from studies elsewhere (Kviz, et al, 1997
; Meredith, et al.
; Wechsler et al.
), a likely consequence of these HCWs’ limited experience with implementing smoking cessation interventions. Through this project, by working to increase the number of HCWs using cessation interventions, HCWs may identify additional barriers to implementation and as an unintended consequence result in additional resistance to the using the interventions.
Another key finding was the absence of comments about the effectiveness of cessation interventions. While striking, this finding may be consistent with another central observation about these communities. The absence of a culture of quitting was evident in earlier community RAPs (Dozier, et al.
) and may be interpreted by DR HCWs as patient disinterest, a factor cited in studies of HCW’s in other countries (Meredith et al.
; Vaughn et al.
Compounding these factors is the finding that DR HCWs were not trained in smoking cessation either as part of their original education or subsequent training. As noted in the literature, this may account for the low priority given to smoking cessation intervention (Katz et al., 2004
; O’Loughlin et al.
; Varona, et al., 2005
). Hartmann et al. (2004)
noted a direct relationship between incorporating cessation intervention practices during residency training with long term adoption of this practice. Lack of intervention training may also account for these HCW’s failure to recognize that environmental tobacco control efforts or their absence (e.g. tobacco company advertising; governmental regulations) affects smoking initiation or prevalence.
Although differences in attitudes about smoking cessation were not found across HCW types, HCWs did differentiate among their roles related to smoking cessation. MDs were viewed as primarily responsible. This is similar to the previously findings from Silas et al. (2008) and those reported by Kviz et al. (1997
) who noted that among privately insured patients over age 50, provider type was the key predictor for whether the individual asked about smoking with physicians more likely to ask than nurses. While Gorin and Heck (2002)
noted that physicians were more effective than the others, they also documented that the more individuals (e.g. other staff in a practice or clinic) involved in the cessation effort the higher the quit rates. As noted by Katz, HCW training can increase the involvement of others such as nurses or medical assistants in cessation interventions. Some HCWs, such as healers and boticarios, did not view themselves as having a role in tobacco cessation interventions.
It is unclear whether these findings are due to attributes specific to the DR or would be found in similar communities in other countries. HCW studies in countries with limited tobacco control initiatives typically include students rather than practicing HCWs and are often limited to urban areas (GTSS Collaborative Group, 2006
), making comparisons to our findings difficult. Alternatively, since the HCWs interviewed received their training from DR-based programs, their training, and in turn their actual practices, may be more in line with in-country attitudes and regulations (e.g. government) rather than by external influences (e.g. receiving training outside the DR). This along with the long-standing influence of the tobacco industry may account for these unique results.
Based on the experience of other countries with more mature tobacco control initiatives, building tobacco interventions into routine care is fundamental to success. Engaging HCWs not only raises their awareness of the importance of intervening but can increase their intervention effectiveness. Furthermore by building intervention skills across all HCWs, cessation resources are expanded, thereby overcoming a barrier to engaging physicians in cessation (availability of referral resources). Increasing resources not only helps address a community identified priority (greater physician role in cessation) but also increases the opportunity for physicians to refer (Arrange).
Use of the RAP approach provided key information about HCW attitudes and practices toward smoking in the DR and demonstrated the value of gathering community specific data as not all findings were consistent with other published studies. Subsequent to this phase the project conducted surveys in each community including a cohort of smokers and a household surveillance about health and smoking behaviors. Findings from these sources informed the interventions, deployed in the three intervention communities (not identified at the time of data collection). One component, training in cessation, was specifically offer to all HCWs in each intervention community. Additionally cessation specialists (all non-physicians) were trained to serve a local resources to whom smokers desiring to quit could be referred.
Our findings were used to develop systematic HCW surveys and interventions including training programs (Ossip-Klein et al
, accepted for publication). By so doing we sought to engage DR HCWs in the project’s community tobacco cessation interventions.