WHO Library Cataloguing-in-Publication Data Strengthening health systems for treating tobacco dependence in primary care. Contents: Part I: Training for policy-makers: developing and implementing health systems policy to improve the delivery of brief tobacco interventions; Part II: Training for primary care service managers: planning and implementing system changes to support the delivery of brief tobacco interventions; Part III: Training for primary care providers: brief tobacco interventions; Part IV: Training for future trainers: applying adult education skills to training. 1.Tobacco use disorder - prevention and control. 2.Smoking - prevention and control. 3.Smoking cessation. 4.Primary health care. 5.Delivery of health care. 6.Capacity building. 7.Teaching materials. I.World Health Organization. ISBN 978 92 4 150541 3 (NLM classification: HD 9130.6)
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Strengthening health systems for treating tobacco dependence in primary care Part I: Training for policy-makers: Developing and implementing health systems policy to improve the delivery of brief tobacco interventions
Strengthening health systems for treating tobacco dependence in primary care / Part I
Contents
CONTENTS
Training Package Overview........................................................................................................................... 4 Part I: Training for policy-makers: Developing and implementing health systems policy to improve the delivery of brief tobacco interventions.............................................................................. 9 Introduction.................................................................................................................................................. 9 Facilitators’ guide for the full version ................................................................................................... Module 1: Treatment of tobacco dependence: a top priority for health-care systems .................. Module 2: WHO Health System Framework and steps for formulating policy interventions to strengthen health systems ........................................................... Module 3: Assessing the performance of brief tobacco interventions in primary care.................. Module 4: Identifying the causes of poor performance...................................................................... Module 5: Defining appropriate health system strengthening strategies ....................................... Module 6: Establishing and implementing health systems policies ................................................ Module 7: Monitoring and Evaluation ................................................................................................... 14 14 16 18 19 20 21 23
Facilitators’ guide for the simplified version ....................................................................................... 25 Participants’ workbook for the full version .......................................................................................... Module 1: Treatment of tobacco dependence: a top priority for health-care systems .................. Module 2: WHO Health System Framework and steps for formulating policy interventions to strengthen health systems................................................................................................ Module 3: Assessing the performance of brief tobacco interventions in primary care...................... Module 4: Identifying the causes of poor performance...................................................................... Module 5: Defining appropriate health system strengthening strategies ....................................... Module 6: Establishing and implementing health systems policies ................................................ Module 7: Monitoring and Evaluation ................................................................................................... 28 28 34 40 43 49 55 60
Participants’ workbook for the simplified version .............................................................................. 65 References and resources ......................................................................................................................... 71 Appendix: Sample evaluation form ....................................................................................................... 74
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TRAINING PACKAGE OVERVIEW INTRODUCTION Treatment of tobacco use and dependence is mandated in Article 14 of the World Health Organization (WHO) Framework Convention on Tobacco Control (WHO FCTC) as a key component of comprehensive tobacco control strategy. The tobacco-related death and disease burden can be reduced considerably in the short to medium term if population-level tobacco control policies are complemented by interventions to support tobacco users to quit. Guidelines for the implementation of Article 14 of the WHO FCTC identify the key effective measures needed to promote tobacco cessation and to incorporate tobacco dependence treatment into national tobacco control programmes and health systems. Parties are encouraged to use these guidelines to assist them in fulfilling their obligations under the WHO FCTC and in protecting public health. Tobacco dependence treatment is recommended by WHO as part of a comprehensive package of essential services for prevention and control of non-communicable diseases (NCDs) in primary care in accordance to the revised draft of the WHO Global Action Plan for the Prevention and Control of NCDs (2013-2020). This idea has already been reflected in this training package by emphasizing it as part of WHO MPOWER comprehensive tobacco technical assistance package, focusing on integration of tobacco dependence treatment into primary care. In order to implement successfully the plan, the provision of technical resources and support to countries is needed for integrating tobacco dependence treatment into their NCDs prevention and control programmes, along with high-level political commitment and concerted involvement of governments, communities and health-care providers. The overall goal of this training package is to provide a technical resource to assist countries to integrate brief tobacco interventions (brief advice) into primary care as part of their efforts to implement the WHO FCTC Article 14 guidelines and the WHO NCDs Global Action Plan. WHY FOCUS ON BRIEF TOBACCO INTERVENTIONS? Although all countries should aim to develop a comprehensive system to provide a range of interventions for tobacco cessation and treatment of tobacco dependence, the guidelines for implementation of Article 14 of the WHO FCTC recommend that Parties use a stepwise approach to develop tobacco dependence treatment, taking into account the fact that resources are always limited and very few countries can develop a comprehensive system simultaneously. Using existing resources and infrastructures as much as possible to ensure that tobacco users receive at least brief advice has been recommended to Parties as one of their first steps towards developing a comprehensive tobacco dependence treatment system. In this way, Parties can develop their tobacco dependence treatment system as rapidly as possible and at as low a cost as possible. In line with the recommendation of the Article 14 guidelines, this training package aims to assist countries in taking their first action towards providing comprehensive tobacco dependence treatment to all tobacco users by integrating brief tobacco interventions into their primary care services. This has the potential to: − reach more than 80% of all tobacco users per year; − trigger 40% of cases to make an attempt to quit; − help 2−3% of those receiving brief advice quit successfully; − form a promising referral source and create demand for more intensive tobacco cessation services such as quit-lines and specialized tobacco dependence treatment.
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Training Package Overview
WHY FOCUS ON PRIMARY CARE Despite the evidence on the effectiveness and cost-effectiveness of brief tobacco interventions, more than 50% of health-care providers, especially those in low- and middle-income countries do not routinely deliver these interventions. The low availability of tobacco cessation services in countries is mainly caused by the weaknesses of their health systems. Guidelines for implementation of Article 14 of the WHO FCTC highlighted the central role of the health system and recommended that brief advice be integrated into all health systems. Although the brief tobacco interventions should be made available throughout a country's health system at all levels of service delivery, the primary care setting should be the main focus. It has the potential to reach the majority of tobacco users in many countries, where the cost of service delivery in primary care settings is relatively low. STRUCTURE AND CONTENT Structure of the training package The training package is organized in four parts. Three separate parts were developed for training of policy-makers, primary care service managers and primary care providers, based on the understanding that the whole health-care system needs to function well and all heath system actors should improve their skills and play a better role in order to improve the integrated delivery of brief tobacco interventions in primary care. In order to meet the need for training the trainers, this package also includes a fourth part on “Applying adult education skills to training”. Relevant parts and target audiences are summarized in the Table A1. Table A1. The parts of the training package and their target audiences Subject of each part Part I: Developing and implementing health systems policy to improve the delivery of brief tobacco interventions (seven modules) Part II: Planning and implementing system changes to support the delivery of brief tobacco interventions (seven modules) Target audiences Policy-maker: a person with power to influence or determine policies and practices at national, regional, or local level.
Primary care service manager: an administrator with special training and skills, who is concerned with the management, planning and provision of primary care services. Primary care service managers could be general practitioners (GP) and managers of community health services, or they could be health-care workers, although normally they do not provide directly primary care services. Primary care provider: a person who helps in identifying or preventing or treating illness or disability in primary care settings. Future trainer: a person who has basic knowledge and skills of medical education, and is willing to provide further training for policy-makers, primary care service managers or primary care providers.
Part III: Brief tobacco interventions (nine modules)
Part IV: Applying adult education skills to training (one module)
Each part of the training package consists of a Facilitators’ guide and Participants’ workbook and includes a certain number of training modules, depending on the number of topics and activities needed. Each training module is presented in a four-step format: preparation, presentation, practice and evaluation. This structure ensures that we use a variety of adult teaching methods and provide sufficient opportunity for participants to share their experiences and to practise their newly learned skills.
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Training Package Overview
Content of the training package The training package content is developed based on: − guidelines for implementation of Article 14 of the WHO FCTC adopted by the WHO FCTC Conference of the Parties; − the “Offer help to quit tobacco use” component of WHO’s MPOWER package; − the WHO Health System Framework (the six building blocks of a health system); − best available scientific evidence, best practice approaches and models in the field of tobacco dependence treatment and health system strengthening. Analysis of the tasks required for policy-makers, primary care service managers and primary care providers to integrate brief tobacco interventions into existing primary care services revealed that the whole health-care system needs to be strengthened in order to improve the delivery of brief tobacco interventions in primary care. Therefore, reflecting their needs, in line with the WHO Health System Framework, the training package content was designed to improve the knowledge and skills of policymakers, primary care service managers and primary care providers to enable them to bring about changes in some or all of the six health system building blocks (leadership and governance, service delivery, health workforce, information, medical products and technologies, and financing). Table A2 summarizes the system changes that three target audiences need to bring about for improving the integrated delivery of brief tobacco interventions in primary care settings. Table A2. Target audiences and projected system changes Leadership/ governance Service delivery Health workforce Information Medical products and technologies Financing
Policy-makers Primary care service managers Primary care providers
HOW TO USE THIS TRAINING PACKAGE This training package is meant to be a capacity-building and training tool for WHO, WHO Member States and international partners to help them improve their contribution to the implementation of the WHO FCTC Article 14 guidelines and the WHO NCD Action Plan. WHO recommends that implementing this training package to integrate brief tobacco interventions into existing primary care services should be conducted in conjunction with other population-level tobacco control measures covered by the WHO FCTC in order to achieve a synergistic effect and maximize its impact. It is also recommended that this training package is implemented to improve the delivery of brief tobacco interventions as a key component of integrated health programmes dealing with NCDs and tuberculosis, as well as with maternal and child health in primary care.
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Training Package Overview
Ideally a country should use the whole package to conduct training for policy-makers, primary care service managers and primary care providers in order to promote the effective integration of brief tobacco interventions into existing primary care services. However, a country may choose to train just one or two of these groups, taking into account national circumstances and priorities. When the training package is implemented either fully or partially in a specific country, it should be adapted to suit countryspecific situations. The entire training for policy-makers, primary care service managers and primary care providers lasts a total of 7.5−9 days with 2.5−3 days for each. The training for future trainers will last 0.5−1 day. MORE INFORMATION AND GUIDANCE This training package is intended for use by staff of WHO and government departments of WHO Member States. However, its components and tools can be used in other contexts to promote treatment of tobacco dependence in primary care. If you use this package outside the context of a WHO-sponsored training workshop, please let us know. Your experience and feedback will help WHO improve the package and share lessons learned with others. For feedback and additional guidance in implementing the package, please contact: Prevention of Noncommunicable Diseases World Health Organization Avenue Appia 20 1211 Geneva 27, Switzerland Email: pnd@who.int Telephone: + 41 22 791 21 11 www.who.int/tobacco/en
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Training Package Overview
ACKNOWLEDGEMENTS The WHO Department of Prevention of Noncommunicable Diseases (PND) developed this training package. We thank the regional advisers for tobacco control and their teams for their assistance in developing and piloting of this package. A large number of international experts from various institutions and agencies were involved as contributors. Dongbo Fu coordinated the production of this package under the direction of Armando Peruga and Douglas Bettcher. Miriamjoy Aryee-Quansah provided administrative support. The following people drafted this training package: Lisa Andrews, Elizabeth Dubois, Dongbo Fu, Lisa McNally, Salman Rawaf, Etta Short and Ken Wassum. This package was reviewed at the different phases of its preparation by OA Ayo-Yusuf, Douglas Bettcher, Stella Bialous, Adriana Blanco, Fatimah EL-AWA, Mahmoud Elhabiby, Dongbo Fu, Nyo Nyo Kyaing, Svetla Loukanova, Kristina, MAUER-STENDER, Andy McEwen, Hayden McRobbie, Susan Mercado, Yumiko Mochizuki, Hernan Montenegro, Ezra Ogwell OUMA, Armando Peruga, Denis Porignon, Martin Raw, Salman Rawaf, Gerard Schmets, Ken Wassum and Dan Xiao. Interim versions of this package were piloted at workshops in the WHO African Region (Mauritius), the WHO Region of the Americas/Pan American Health Organization (Bahamas, Barbados, Panama and Trinidad and Tobago), the WHO Eastern Mediterranean Region (Iran and Jordan with participants from Egypt and Iraq), and the WHO Western Pacific Region (Malaysia and Philippines). The comments and suggestions provided by participants at these workshops have been used to refine and improve the training package. WHO would like to acknowledge Mayo Clinic, the British Columbia Lung Association and the British Columbia Provincial Government who granted permission for use of their materials as part of the training package. Health Canada funded the piloting of this training package in the Region of the Americas. The Ministry of Health, Labour and Welfare (MHLW) of Japan funded the pilot of this training package in the African Region and the Western Pacific Region. The printing of this training package was made possible by funding from the MHLW, Japan.
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PART I: TRAINING FOR POLICY-MAKERS: DEVELOPING AND IMPLEMENTING HEALTH SYSTEMS POLICY TO IMPROVE THE DELIVERY OF BRIEF TOBACCO INTERVENTIONS
INTRODUCTION The role of policy-makers in strengthening health systems to deliver brief tobacco interventions in primary care is to form policies, strategies and health plans to support system changes in relation to the six health system building blocks. The purpose of Part I is to improve policy-makers’ knowledge and skills to enable them to recognize the treatment of tobacco dependence as a priority for their health system and to develop supportive policies to strengthen health systems to improve the delivery of brief tobacco interventions in primary care as part of their efforts to implement the WHO FCTC and to control NCDs. LEARNING OBJECTIVES, SKILL DEVELOPMENT AND OUTCOMES Learning objectives Upon completion of this training participants will be able to: − recognize treatment of tobacco dependence as a key component of any comprehensive tobacco control programme; − make treatment of tobacco dependence a top priority for their health systems; − list policy-makers’ responsibilities for strengthening health systems to improve the delivery of brief tobacco interventions in primary care; − apply the WHO Health System Framework to diagnose the causes of poor performance of brief tobacco interventions in primary care and to develop health systems policies to improve the performance; − describe the five steps for health policy formulation (AIDE-ME); − develop action plans for assessing the performance of brief tobacco interventions in primary care; establishment, implementation, monitoring and evaluation (M&E) of new health systems policies. Skills developed 1. Ability to use the WHO Health System Framework to diagnose the causes of poor performance in delivering brief tobacco interventions in primary care settings. 2. Ability to identify appropriate strategies and policy interventions to tackle health system constraints to improve the performance of brief tobacco interventions delivery in primary care. 3. Ability to effectively engage all stakeholders in the process of policy development and implementation. 4. Ability to develop an implementation plan and an M&E plan for new health system policies. Outcomes 1. Increased political commitment to strengthening health systems to improve the delivery of brief tobacco interventions in primary care. 2. Action plans for diagnosing the performance of brief tobacco interventions in primary care; establishment, implementation, monitoring and evaluation of new health systems policies to improve the delivery of brief tobacco interventions in primary care settings.
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Training for policy-makers
STRUCTURE AND CONTENT The full version The full training for policy-makers consists of seven modules. Each of the seven modules addresses a specific issue or phase of the process of developing and implementing health systems policies to integrate brief tobacco interventions into primary care services. Each training module is presented in a four-step format, namely: preparation, presentation, practice and evaluation. The modules are summarized below. Further guidance for facilitators follows in the detailed Facilitators’ guide. Module 1: Treatment of tobacco dependence: a top priority for health-care systems Module 2: WHO Health System Framework and steps for formulating policy interventions to strengthen health systems Module 3: Assessing the performance of brief tobacco interventions in primary care Module 4: Identifying the causes of poor performance Module 5: Defining appropriate health systems strengthening strategies Module 6: Establishing and implementing health systems policies Module 7: Monitoring and Evaluation If all seven modules are used, the training workshop duration is 2.5 days. However, the duration and details covered in each module should be adapted to the needs of the participants. Their needs will depend on their experience and knowledge of the issue, the stage of WHO FCTC implementation in the country, and the strengths and weaknesses of their health system. A sample agenda for the training workshop of 2.5 days is provided below. Day 1 8:30 – 9:00 9:00 – 9:30 9:30 − 10:30 10:30 − 10:45 10:45 − 11:15 11:15 − 12:15 12:15 − 13:15 13:15 − 14:15 14:15 − 15:00 15:00 − 15:30 15:30 − 16:30 16:30 − 17:00 Registration Welcome and Workshop Overview Participant introductions Module 1: Treatment of tobacco dependence: a top priority for health-care systems (1) Coffee break Module 1: Treatment of tobacco dependence: a top priority for health-care systems (2) Module 2: WHO Health System Framework and steps for formulating policy interventions to strengthen health systems (1) Lunch Module 2: WHO Health System Framework and steps for formulating policy interventions to strengthen health systems (2) Module 3: Assessing the performance of brief tobacco interventions in primary care (1) Coffee break Module 3: Assessing the performance of brief tobacco interventions in primary care (2) Daily wrap-up
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Training for policy-makers
Day 2 8:30 – 9:00 9:00 − 10:45 10:45 − 11:00 11:00 − 12:45 12:45 − 13:45 13:45 − 15:00 15:00 − 15:30 15:30 − 16:30 16:30 − 17:00 Day 3 8:30 – 9:00 9:00 − 10:30 10:30 − 10:45 10:45 − 11:45 11:45 − 12:30 Interactive discussions Module 7: Monitoring and evaluation (1) Coffee break Module 7: Monitoring and evaluation (2) Closing session Workshop evaluation Interactive discussions Module 4: Identifying the causes of poor performance Coffee break Module 5: Defining appropriate health systems strengthening strategies Lunch Module 6: Establishing and implementing health systems policies (1) Coffee break Module 6: Establishing and implementing health systems policies (2) Daily wrap-up
The simplified version Considering that policy-makers are generally not available to attend a long training workshop, a simplified training module has been developed for a half-day workshop for policy-makers. The purpose of this simplified version of the training is to increase the awareness of policy-makers of the importance of tobacco dependence treatment as part of a comprehensive tobacco control strategy and the need to strengthen health systems to support the integrated delivery of brief tobacco interventions in primary care. The simplified training module is also presented in the four-step format: preparation, presentation, practice and evaluation. This simplified module has five main components, namely: − the current situation of tobacco use and tobacco control in the country; − what a country can do to support tobacco users to quit, and how; − prioritizing tobacco dependence treatment in primary care; − WHO Health System Framework: a tool for strengthening health systems; − policy-makers’ commitment to strengthening health systems to improve the delivery of brief tobacco interventions in primary care.
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Training for policy-makers
Below is a sample agenda for organizing a half-day training workshop for policy-makers. Half day training workshop 8:30 – 9:00 9:00 − 9:30 Registration Welcome and workshop overview Participant introductions
Section 1: Tobacco use: a big public health problem in the country 9:30 − 9:50 The current situation of tobacco use and tobacco control in your country
Section 2: What a country can do to support tobacco users to quit, and how 9:50 − 10:20 Supporting tobacco users to quit: the Parties’ obligations under the WHO FCTC The WHO FCTC Article 14 guidelines recommendations 10:20 − 10:40 Coffee break
Section 3: Prioritizing tobacco dependence treatment in primary care 10:40 − 11:10 Why treatment of tobacco dependence should be a top priority for health-care system? The need to strengthen health systems to promote brief tobacco interventions in primary care Section 4: WHO Health System Framework: a tool for strengthening health systems 11:10 − 12:25 WHO Health System Framework and WHO definition of health system strengthening Practise using the WHO Health System Framework to identify effective policy interventions to promote brief tobacco interventions Section 5: Your commitment to strengthening health systems to improve the delivery of brief tobacco interventions in primary care 12:25 − 13:25 13:25 − 13:45 Group presentation and discussion on effective policy interventions to promote brief tobacco interventions in primary care Closing session Workshop evaluation
PREPARING FOR THE TRAINING Organizing a training workshop requires many practical considerations to be addressed, such as when and where the training will be provided, forming a facilitation team, setting up a workshop programme and agenda, selecting participants, and logistics and materials. The facilitation team The training should be delivered by an expert facilitation team identified by the organizer in consultation with key local partners. The team should include: − a lead facilitator with detailed expertise in treatment of tobacco dependence and health systems and experience in facilitating workshops; − one or two additional facilitators with expertise in one or more aspects of tobacco control, medical education, health systems and policy; − additional content presenters as necessary. The facilitation team should be supported by one or more logistics assistants to facilitate logistical needs during the workshop, including production and reproduction of materials.
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Training for policy-makers
Workshop programme and schedule Prior to the training, the organizer and facilitators should gather as much information as possible about the country situation and the knowledge, skills and needs of participants in order to determine the training content and structure. If necessary, adjustments can be made to the content and structure to suit the situation. The organizer and facilitators will then need to design an appropriate training schedule or agenda based on the content they want to offer to the participants, the time needed for each module and the overall timeframe of the workshop. Please try to avoid creating an overcrowded schedule during the planning of the schedule. Selecting participants The workshop is targeted at those who have power to influence or determine policies and practices at national, regional or local level. These could be health authorities at national level (Ministry of Health), or at sub-national level (provincial, regional and district health bureau). The choice of participants will depend on the goals of the training. For instance, a workshop for establishing health-system polices to integrate brief tobacco interventions into a national health system will require more national representatives than local, and vice versa. It is recommended that the workshop be conducted with a maximum of 20 participants. Logistics The workshop requires standard meeting/training tools and facilities, namely: − one main meeting room, with participants seated around small tables in small groups; − one or two additional break-out rooms if the large room cannot accommodate small group discussions; − flipcharts and markers (one for each small group); − projector and screen for presentations; − laptop computer with speakers for presentations; − presenter’s microphone; − portable microphones for discussions (optional); − desktop computer, printer and photocopier for document production during the workshop (optional). Materials All the workshop training and background materials are provided online by WHO. These include: − the Facilitators’ guide; − presentations; − the Participants’ workbook; − workshop evaluation forms (see Appendix for sample evaluation form). The References and Resources section contains hyperlinks to the relevant materials needed throughout the workshop. In addition to online materials, each participant should receive a binder or folder with key printed materials, particularly: − handouts of presentations; − key resource documents for each theme. The facilitation team should decide which resources are most relevant to the participants and should include them in the printed materials. The facilitation team should also ensure that key materials are available in the language of the participants. 13
FACILITATORS’ GUIDE FOR THE FULL VERSION Module 1: Treatment of tobacco dependence: a top priority for health-care systems Duration Objectives 1.5 hours Upon completion of this module, participants will be able to: − recognize treatment of tobacco dependence as a key component of any comprehensive tobacco control programme; − list the reasons for countries to make treatment of tobacco dependence a top priority for their health-care systems; − state rationales for promoting access to treatment of tobacco dependence in primary care settings.
Time
Facilitator activity
Participant activity
Audiovisual
Preparation 15 minutes Tell stories about: • what happened after the smoke-free laws were implemented in the UK; • what happened after the USA raised federal tobacco tax in early 2009; • what happened after the tax on tobacco increased in Hong Kong SAR, China. Explain that this training workshop is a chance to self-define the need for scaling up tobacco dependence treatment in primary care and to improve necessary skills for policy change. Presentation 15 minutes Use the WHO FCTC to explain: • Only a comprehensive tobacco control strategy can reverse the global tobacco epidemic. • Treatment of tobacco dependence should not be neglected as a key component of any comprehensive tobacco control programme because tobacco control interventions are complementary. • Providing support for tobacco users to quit can also help reduce their resistance to the implementation of population-level tobacco control policies. Use the WHO MPOWER package to explain how WHO provides countrylevel assistance to promote tobacco dependence treatment. Ask: • Which article of the WHO FCTC is related to treatment of tobacco dependence? • Which measure in the MPOWER package is related to treatment of tobacco dependence? Refer participants to the workbook; show the core provisions in the WHO FCTC and the nature of the MPOWER package. 10 minutes State that a country’s health system should assume the major responsibility for treating tobacco dependence and every country should make the treatment of tobacco dependence a top priority for their health-care system. Workbook, flipchart or whiteboard, PowerPoint Ask participants to brainstorm: why the treatment of tobacco dependence Brainstorm the reasons. presentation Part Ishould be a top priority for a health-care system. Module 1-C Write down participants’ responses on a flipchart page or a whiteboard. Refer participants to the workbook, use PowerPoint slides to present the reasons: • Treating tobacco dependence is the best thing that the health system can do to improve health for all. • Treating tobacco dependence is one of the most cost-effective among other common medical interventions. The presentation should emphasize the points that participants do not mention in the brainstorming exercise. 14
Conclude that implementing populationlevel tobacco control policies can motivate people to stop smoking, and can create demand for tobacco dependence treatment.
Workbook, PowerPoint presentation Part IModule 1-A
Anticipated response: Article 14 of the WHO FCTC and Policy “O” (Offer help to quit tobacco use) of the MPOWER package.
Workbook, flipchart or whiteboard, PowerPoint presentation Part IModule 1-B
Strengthening health systems for treating tobacco dependence in primary care / Part I
Facilitators’ guide for the full version
Time
Facilitator activity
Participant activity
Audiovisual
Presentation 10 minutes Explain that, although the treatment of tobacco dependence should be made available in a country's entire health system at all levels of service delivery, including primary, secondary and tertiary health care settings, primary care settings should be the main focus. Refer participants to the workbook, use PowerPoint slides to present the rationales for promoting access to tobacco cessation services in primary care settings: • The public health impact of an intervention/service depends on effectiveness, reach and delivery cost. • The primary care can help: − reach the majority of tobacco users in many countries; − reduce the delivery cost by using the integrated service delivery model. Ask for the conclusion that: • Consistent provision of treatment of tobacco dependence to tobacco users in primary care settings could have a substantial public health benefit, as there are various existing opportunities and entry points in primary care to reach the majority of tobacco users. Practice 20 minutes Assign participants to pair up with the person sitting next to them to list Work in pairs to list Workbook all existing effective tobacco cessation services in primary care settings. existing effective tobacco cessation services. PowerPoint presentation Part IModule 1-D
Evaluation 20 minutes Ask volunteers to share their lists of existing effective tobacco cessation services. Make sure that participants understand the following statements: • Countries should aim to develop a comprehensive system to provide a range of interventions for tobacco cessation and treatment of tobacco dependence. • The guidelines for implementation of Article 14 of the WHO FCTC recommend that countries use a stepwise approach to developing their treatment system: if they cannot do it simultaneously, they should at least ensure that tobacco users receive brief tobacco interventions in primary care settings. • Many opportunities and entry points exist in primary care to reach tobacco users and provide them with brief tobacco interventions. If health-care system does not function well, it may not be able to respond adequately to such opportunities. Prompt that, in line with the Article 14 guidelines, and considering the potential public health impact, this training is provided to assist countries to take one of their first actions towards developing a comprehensive tobacco dependence treatment system, namely: to strengthen health systems to improve the delivery of brief tobacco interventions in primary care. Share with the group their lists of existing effective tobacco cessation services. Everyone helps critique and give feedback. Flipchart or whiteboard, PowerPoint presentation Part IModule 1-E
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Facilitators’ guide for the full version
Module 2: WHO Health System Framework and steps for formulating policy interventions to strengthen health systems Duration Objectives 2 hours Upon completion of this module participants will be able to: − define a health system and health system strengthening; − state the functions, structure and goals of a health system; − describe the WHO Health System Framework; − describe the five steps for health policy formulation (AIDE-ME); − list policy-makers’ responsibilities for strengthening health systems to promote brief tobacco interventions; − show political commitment for strengthening health systems to improve the delivery of brief tobacco interventions in primary care.
Time
Facilitator activity
Participant activity
Audiovisual
Preparation 20 minutes State that any strategy for strengthening health systems to improve delivery of brief tobacco interventions needs the knowledge of health system basics, which are learning objectives for this module. Refer participants to the workbook, and do the quiz for the following questions: • What is health system? • What are health system goals? • What is health system strengthening? Tell participants that they will have an opportunity to improve their knowledge about health systems in this module. Presentation 10 minutes Use PowerPoint slides to present: • WHO definition of a health system; • WHO Health System Framework. Explain that the WHO Health System Framework (six building block framework) can help one understand the structure, goals and functions of a health system. Be sure to use examples to explain: • The structure of a health system( six building blocks); • The multiple goals of a health system: − improving health and health equity, which is the defining goal for a health system, − responsiveness to needs, − fairness in financial contribution; • The basic functions of a health system: − stewardship(governance), − creating resources, − delivering services, − financing; Introduce the results chain and explain that: • The route from inputs, processes and outputs to health impact is through achieving intermediate objectives: greater access to and coverage of effective health interventions (enhancing the system’s performance). • These intermediate objectives can be targeted and changed by health system strengthening interventions. Refer to the workbook. Workbook, flipchart or whiteboard, PowerPoint presentation Part IModule 2-A Do the quiz independently. Workbook
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Facilitators’ guide for the full version
Time
Facilitator activity
Participant activity
Audiovisual
Presentation 15 minutes Introduce the WHO definition of health systems strengthening. Emphasize that the WHO Health System Framework can be a useful tool for strengthening health systems to promote brief tobacco interventions in primary care because it shows practical ways to strengthen health systems by using six operational “building blocks”. Emphasize that, for the rest of the course, participants will learn how to use the WHO Health System Framework as a tool to strengthen their health systems to deliver brief tobacco interventions. 15 minutes Introduce the five steps for health policy formulation. Explain that: • The WHO Health System Framework reveals the content areas of health system strengthening interventions, but it does not tell us what to do and how to strengthen each of the six building blocks. • For the purpose of translating the WHO Health System Framework into health system strengthening actions at the operational level, on the basis of the “Health Policy Cycle”, a five-step process (AIDE-ME) is summarized for formulating policy interventions to strengthen health systems, i.e.: 1. Assess health systems performance. 2. Identify causes of poor performance and opportunities to improve. 3. Define appropriate health system strengthening strategies. 4. Establish and implement health systems policies. 5. Monitoring and Evaluation. Use a figure to visualize the health policy formulation process. Point out that participants will have opportunities to go through each of these five steps to improve necessary skills for formulating health policy. Practice 30 minutes Prompt participants that a health systems strengthening is a complicated process, which involves all key actors of a health system, including policymakers. Policy-makers have key roles and responsibilities in strengthening health systems to promote access to brief tobacco interventions. Assign participants to work in small groups to brainstorm and list the responsibilities of policy-makers for strengthening health systems to improve the delivery of brief tobacco interventions in primary care. Give the groups a template to make the list according to each of the six building blocks. Evaluation 30 minutes Ask the groups to present their lists of policy-makers’ responsibilities. Refer to the workbook and summarize the roles and responsibilities of policy-makers for strengthening health systems. Ask participants: • As a policy-maker, are you willing to take any action to strengthen health systems to improve the delivery of brief tobacco interventions? Encourage participants to make a statement and measure the political commitment by counting positive statements made by participants. Everyone helps critique and give feedback. Anticipated response: participants express their willingness to take actions. Workbook, PowerPoint presentation Part IModule 2-D Work in small groups Workbook, and use the pre-set flipchart or template to generate a whiteboard list of responsibilities of policy-makers. Refer to the workbook. Workbook, PowerPoint presentation Part IModule 2-C Refer to the workbook. Workbook, PowerPoint presentation Part IModule 2-B
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Facilitators’ guide for the full version
Module 3: Assessing the performance of brief tobacco interventions in primary care Duration Objectives 1 hour 45 minutes Upon completion of this module participants will be able to: − define performance of brief tobacco interventions in primary care; − use appropriate indicators and measurement methods to assess the performance of brief tobacco interventions in primary care; − develop a plan for assessing the performance of brief tobacco interventions in primary care.
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Preparation 15 minutes Ask participants: What is “performance of brief tobacco interventions in primary care”? State that: “Performance” here relates to how well primary care providers perform to deliver brief tobacco interventions. In this module, participants will discuss how to assess the performance of their primary care providers for delivering brief tobacco interventions. Presentation 30 minutes Explain that assessing the performance of brief tobacco interventions in Refer to the workbook. primary care requires an understanding of the objective of strengthening health systems. State that the objective of WHO health systems strengthening for treating tobacco dependence is to achieve universal coverage of brief tobacco interventions for all tobacco users. Ask participants to brainstorm: What indicators can be used to measure the performance of brief tobacco interventions in primary care? Write down participants’ responses. Describe the indicators and measurement methods: • Indicators: − coverage (percentage of tobacco users visiting primary care facilities in the last 12 months who stated they received brief tobacco interventions), − equity in brief tobacco interventions coverage (the level of coverage for different districts and different groups, e.g. poor vs. non-poor, female vs. male); • Data source: − clinical data, − survey. Practice 30 minutes Participants work in small groups to develop a plan for assessing the performance of primary care providers for delivering brief tobacco interventions in their countries. Refer participants to the pre-set template and tell each group that the plan should consist of the following components: • indicators; • data source; • data analysis and synthesis; • data dissemination, communication and use. Participants work in small groups to develop a plan for the assessment of primary care providers’ performance. Workbook Anticipated response: participants participate in the discussion and share their ideas. Workbook, flipchart or whiteboard, PowerPoint presentation Part IModule 3-A Participants respond to the question. Workbook
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Facilitators’ guide for the full version
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Evaluation 30 minutes Ask the groups to present their plans for the performance assessment. Ask for the conclusion that the results of their primary care providers’ performance assessment will guide their decision as to whether or not their primary care providers’ performance needs to be improved. Everyone helps critique and give feedback.
Module 4. Identifying the causes of poor performance Duration Objectives 1 hour 45 minutes Upon completion of this module participants will be able to: − discuss the principles and tools for diagnosing the causes of poor performance of primary care providers in delivering brief tobacco interventions; − describe steps to identify the causes of poor performance in delivering brief tobacco interventions in primary care settings.
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Preparation 15 minutes State that this module is going to discuss how to do a DIAGNOSIS. Use PowerPoint slides to explain the definition of “diagnosis”; that “diagnosis of the causes of poor performance” requires us to identify the root causes of low coverage of brief tobacco interventions in primary care settings that can be changed through policy interventions. Point out that the WHO Health System Framework (six building blocks) is a good tool for identifying the underlying causes of poor performance in delivering brief tobacco interventions. Presentation 20 minutes Explain why the WHO Health System Framework can be a good analytical Refer to the workbook. tool for diagnosing the causes of poor performance in delivering brief tobacco interventions. Use one specific example to demonstrate how the diagnostic process operates and to describe the steps of using the WHO Health System Framework to identify the underlying causes of poor performance in delivering brief tobacco interventions in primary care settings. Practice 40 minutes Assign participants to work in small groups to identify the causes of poor Work in small groups to Workbook performance in delivering brief tobacco interventions in primary care identify the causes of using the WHO Health System Framework. poor performance in delivering brief tobacco Each group works on one specific performance problem in delivering interventions in their brief tobacco interventions in their primary care settings. primary care settings. Give each small group a pre-set template to write down their results. Workbook, PowerPoint presentation Part IModule 4-B Workbook, PowerPoint presentation Part IModule 4-A
Evaluation 30 minutes Ask the groups to present their results. Ask for the conclusion that: • The diagnostic analysis of the performance problem requires multiple successive steps, and the WHO Health System Framework can be a helpful organizing device for this analysis. • Solving performance problems may well require action on more than one cause at a time (i.e. changing more than one building block) because a health system is a set of interconnected parts that must function together to be effective. Everyone helps critique and give feedback. Conclude that more than one building block should be changed for achieving better health system performance. 19
Strengthening health systems for treating tobacco dependence in primary care / Part I
Facilitators’ guide for the full version
Module 5: Defining appropriate health system strengthening strategies Duration Objectives 1 hour 45 minutes Upon completion of this module participants will be able to: − describe the advantages and disadvantages of different approaches to strengthening health systems; − discuss appropriate strategies for taking advantage of existing opportunities to improve the performance of brief tobacco interventions in primary care while other programmes also benefit.
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Preparation 15 minutes Ask participants: • Where are we now on health policy formulation journey? Review the process of the health policy formulation journey (AIDE-ME) and tell participants that they are now moving into the third step to define appropriate strategies to tackle the causes of poor performance in delivering brief tobacco interventions, as identified in Module 4. Presentation 30 minutes Explain three common approaches to strengthening health systems: Refer to the workbook. • the system-wide approach (horizontal approach); • the disease/service/intervention-specific approach (vertical approach); • the matrix approach. Make sure to emphasize the advantages and limitations of the horizontal and vertical approaches and the rationale for adopting the matrix approach in order to: • have a comprehensive package of different types of services; • arrange a coordinated care at the service delivery point with integration of tobacco cessation interventions into other primary care services; • achieve continuity of care over time; • have integrated policy-making and management; • have coordination between the tobacco cessation services and other social services. Explain that the key element of a matrix approach is INTEGRATION. Emphasize that participants should use a health system strengthening approach that focuses on integration of brief tobacco interventions into existing primary care services. Practice 30 minutes Assign participants to work in small groups to define appropriate integration strategies for strengthening health systems to improve the performance of brief tobacco interventions delivery. Ask each group to work on one pre-identified major health system constraint. Remind participants that the strategies should focus on integration and should have a balance between shorter-term progress and long-term improvement in the coverage of brief tobacco interventions. Give participants a pre-set template to write down their results. Evaluation 30 minutes Ask the groups to present their results. Ask for the conclusion that strategies focusing on integration are appropriate ways for strengthening health systems to improve the performance of delivery of brief tobacco interventions. 20
Respond to the question.
Workbook, PowerPoint presentation Part IModule 5-A
Workbook, PowerPoint presentation Part IModule 5-B
Work in small groups Workbook to define appropriate health system strengthening strategies for scaling up brief tobacco interventions in primary care settings. Each group works on one specific health system constraint.
Everyone helps critique and give feedback.
Workbook
Strengthening health systems for treating tobacco dependence in primary care / Part I
Facilitators’ guide for the full version
Module 6: Establishing and implementing health systems policies Duration Objectives 2 hours 10 minutes Upon completion of this module participants will be able to: − discuss the importance of involving interest groups in the process of policy development; − describe the strategic way to engage all stakeholders; − develop health systems policies based on predefined integration strategies; − list basic organizational tasks for implementing health systems policies effectively; − develop an implementation plan.
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Preparation 15 minutes Explain that the integration strategies defined in step “D” will give participants direction and scope as to what kind of health system policies or interventions they need in order to improve the performance of brief tobacco interventions delivery in primary care settings. In this module, participants will practise how to develop and implement health system policies to realize predefined integration strategies. Ask participants: Respond to • What is the process to develop a national health policy in your countries? the question. Prompt that no matter what process or steps they have to go through to develop and implement national health policy, it is very important to engage all relevant stakeholders in the process. Presentation 25 minutes Ask participants to brainstorm: • Why it is important to involve all relevant stakeholders in the process of policy development? Write down participants’ responses on a flipchart page or a whiteboard. Explain that: • Involving interest groups in the process of policy development serves at least five functions: − it allows policymakers to hear and take into account interest groups’ concerns; − it increases the acceptance of a policy; − it educates interest groups about the concerns of, and pressures exerted on, policy-makers by other constituencies; − it educates the participants about the details of the policy that ultimately emerge; − it receives authorization and support from the highest political levels. This is particularly important for the treatment of tobacco dependence because, in many countries so far, it has not been given the deserved high priority. Emphasize that policy-makers should lead any participatory process of policy development because participation may get out of the hands of a policy-maker. Therefore, the process of policy development needs to be managed strategically and led by policy-makers. Ask participants to brainstorm: • Who are the relevant stakeholders we need to engage to scale up brief tobacco interventions in primary care settings? Write down participants’ responses on a flipchart page or a whiteboard. Actively participate in the discussion and share their ideas Workbook, flipchart or whiteboard, PowerPoint presentation Part IModule 6-A Workbook
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Facilitators’ guide for the full version
Time
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Presentation 25 minutes Make sure that the key stakeholders include: • senior policy-makers or managers like ministers of health; • actors in other sectors; • NGOs; • academics • health service managers; • health care providers; • community leaders. Ask participants to brainstorm: • What are appropriate strategies for engaging relevant stakeholders? Write down participants’ responses on a flipchart page or a whiteboard. State that there are many strategies for engaging relevant stakeholders, which can be decided on the basis of a stakeholder’s position on the influence/interest grid. 20 minutes Emphasize that good policies are not worth much if they cannot be implemented. Ask participants to brainstorm: • What are the key elements of sound process for implementing health systems policies? Write down participants’ responses on a flipchart page or a whiteboard. Make sure to include the following tasks: • develop an implementation plan; • assemble a team to carry out the plan and assign tasks to team members; • devise and coordinate schedules. Emphasize that sound implementation planning is a key element in ensuring the successful delivery of health systems policies. Describe the key component of an implementation plan. Please make sure to include: • Broad stakeholder involvement and coordination with the country political and institutional cycles; • Resource planning and program budgeting; • Process management; • Ensuring coherence between the national health policy and other operational plans of disease specific programs; • Designing a performance monitoring, evaluation and feedback system (will be discussed in detail in Module 7). Practice 40 minutes Refer participants to the workbook and assign participants to work in small groups to: • design a policy intervention to change a major health system constraint using the strategies generated during Module 5; • develop an implementation plan for implementing that health systems policy. Work in small groups to develop a policy intervention to change one health system constraint using predefined strategies Give participants a pre-set template for the discussion. The implementation as well as a plan to implement the policy. plan should include: • a clear step-by-step task timetable; • the administrative structure to carry out the plan; • an action plan for each of the key tasks (publicity/communication, capacity-building, involving interest groups and relevant stakeholders, monitoring and evaluation); • resources and budget. 22
Workbook, flipchart or whiteboard, PowerPoint presentation Part IModule 6-A Actively participate in the discussion and share their ideas.
Refer to the workbook. Participate in the discussion and share ideas.
Workbook, flipchart or whiteboard, PowerPoint presentation Part IModule 6-B
Workbook
Strengthening health systems for treating tobacco dependence in primary care / Part I
Facilitators’ guide for the full version
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Evaluation 30 minutes Ask group to present their new health systems policies and implementation plans. Emphasize that participants should take action to actually implement their designed health systems policy following its implementation plan. Otherwise, the new policy is meaningless. Encourage participants to establish more new policies to address the other health system constraints that they identified in Module 5 using the principles and tools they have learned. Everyone helps critique and give feedback.
Module 7: Monitoring and Evaluation Duration Objectives 1 hour 45 minutes Upon completion of this module participants will be able to: − define monitoring and evaluation (M&E); − describe the components of the operational framework for monitoring and evaluation of health systems strengthening interventions; − conduct M&E activities; − develop an M&E plan for monitoring and evaluation of health systems strengthening interventions for improving the coverage of brief tobacco interventions.
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Preparation 20 minutes Ask participants to brainstorm: • What is monitoring? • What is evaluation? • Why do we need M&E? Refer participants to the workbook and use PowerPoint slides to review the definition and purposes of monitoring and evaluation. Emphasize that this module will be used to discuss how to develop and implement an M&E plan for monitoring and evaluation of health systems strengthening interventions for improving the coverage of brief tobacco interventions. Presentation 20 minutes Point out that: • In order to develop an M&E plan we shall need to select an operational framework. • WHO recommends a common framework based on the results chain named the Results Framework for monitoring performance and evaluating progress in health system strengthening actions, which includes four major domains: system input and processes, outputs, outcomes and impact. Use PowerPoint slides to explain that the Results Framework has two axes, namely: • On the horizontal axis of the framework, M&E should measure all changes in each of the four steps of the results chain as a result of your health systems strengthening efforts. • The vertical axis of the framework includes four M&E activities: − indicator selection; − data collection; − analysis and synthesis practices; − communication and use of the results for decision-making. Refer to the workbook. Workbook, PowerPoint presentation Part IModule 7-B Anticipated response: participants share their understanding about M&E and the purposes of M&E. Workbook, PowerPoint presentation Part IModule 7-A
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Facilitators’ guide for the full version
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Presentation 15 minutes Describe the steps and activities for M&E of health systems strengthening Refer to the workbook. interventions, namely: 1. Identify a comprehensive list of core indicators that capture all steps of the results chain. 2. Identify associated data sources for each indicator. 3. Analyse and synthesize data using the core indicators and targets. 4. Translate the data into information relevant for decision-making. Refer participants to the workbook and describe the useful information or recommendations that the Results Framework has outlined for conducting each of the four M&E activities. Explain to participants that they will need to develop a comprehensive plan in order to be able to conduct M&E activities effectively. Practice 40 minutes Assign participants to work in small groups to practise developing an M&E plan for monitoring and evaluation of their health systems strengthening interventions for improving the coverage of brief tobacco interventions. Give participants a pre-set template to write down their M&E plans covering all M&E activities, namely: − indicator selection; − data collection; − analysis and synthesis practices; − communication and use of the results for decision-making Evaluation 30 minutes Ask the groups to present their M&E plans. Emphasize that: • Monitoring and evaluation is an integral part of the health systems strengthening process. • Evaluation of the performance of health systems in delivering brief tobacco interventions requires a solid monitoring and evaluation system, and their M&E plan should build on the country health systems surveillance (CHeSS) platform if one exists. Everyone helps critique and give feedback. Agree that M&E is an integral part of the health systems strengthening process. The M&E results should benefit national health information systems and can inform policymaking at all levels. Work in small groups to Workbook develop an M&E plan. Workbook, PowerPoint presentation Part IModule 7-C
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FACILITATORS’ GUIDE FOR THE SIMPLIFIED VERSION Duration Topic Objectives 4 hours Developing and implementing health systems policy to improve the delivery of brief tobacco interventions Upon completion of this module participants will be able to: − acknowledge their obligations under the WHO FCTC to support tobacco users to quit as part of any comprehensive tobacco control programme; − list the reasons for making treatment of tobacco dependence a top priority for their health-care systems; − describe the content areas of health system strengthening interventions: the six health system building blocks identified by WHO; − show political commitment for strengthening health systems to improve the delivery of brief tobacco interventions in primary care. Facilitator activity Participant activity Audiovisual
Time
Preparation 25 minutes Invite participants to share their knowledge of • the prevalence of tobacco use in the country; • the current tobacco control efforts in the country. Use the recent WHO tobacco control country profiles and WHO global report: mortality attributable to tobacco, to provide participants with information about tobacco prevalence, the implementation of tobacco control measures (including treatment of tobacco dependence), and tobacco-attributable deaths in their country. Prompt participants to summarize that tobacco use is a big public health problem in their country, and that urgent action is needed to reduce tobacco use by fully implementing the WHO FCTC. Presentation 15 minutes State that it is a legal obligation for Parties to the WHO FCTC to support Refer to the workbook. tobacco users to quit as part of a comprehensive tobacco control strategy. Make sure to present the following key messages: • The WHO FCTC obligates Parties to implement comprehensive tobacco control measures to reverse the global tobacco epidemic, and treatment of tobacco dependence is a key component of any comprehensive tobacco control programme. • Tobacco control interventions are complementary. For instance: − implementing population-level tobacco control policies (e.g. increasing tobacco taxes and banning smoking in public places) can motivate tobacco users to quit and can create demand for tobacco dependence treatment; − on the other hand, providing support for tobacco users to quit can help reduce their resistance to the implementation of populationlevel tobacco control policies. 15 minutes Present the WHO FCTC Article 14 Guidelines’ recommendations on what a country can do to support tobacco users to quit, and how. What does a country need to do? • All Parties should aim to develop a treatment system to provide a wide range of interventions for tobacco dependence treatment. How does a country develop its treatment system? • Parties should use a stepwise approach to develop their tobacco dependence treatment and should start by integrating brief tobacco interventions into primary care. • Starting with integrating brief tobacco interventions into primary care is the quickest and most efficient way for a country to develop a comprehensive tobacco dependence treatment system because the primary care can help: − reach the majority of tobacco users in many countries; − reduce the delivery cost by using the integrated service delivery model. Refer to the workbook. Workbook, PowerPoint presentation Part Isimplified version-B Agree that tobacco use is a big public health problem in their country, and urgent action is needed. Workbook, PowerPoint presentation Part Isimplified version-A
Workbook, PowerPoint presentation Part Isimplified version-C
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Facilitators’ guide for the simplified version
Time
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Presentation 15 minutes Present evidence on why treatment of tobacco dependence should be a top priority for a country’s health-care system? Make sure to include the following key points: • Treating tobacco dependence is the best thing that a health system can do to improve health for all because: − at individual level, helping smokers quit at age 60, 50, 40 or 30 years gains them, respectively, about 3, 6, 9 or 10 years of life expectancy; − at population level, it is estimated that if adult tobacco consumption were to decrease by 50% by the year 2020, about one third of global tobacco-related deaths could be avoided. • Treating tobacco dependence is one of the most cost-effective among other common medical interventions. 15 minutes Emphasize the need to strengthen health systems to improve delivery of brief tobacco interventions. Present the following reasons: • Despite the evidence on the effectiveness and cost-effectiveness of tobacco dependence treatments, these are scarce in low- and middleincome countries where health-care providers do not routinely carry out even brief tobacco interventions. The main reasons include: − health-care providers’ lack of knowledge and training on treatment of tobacco dependence; − lack of integration of tobacco dependence treatment into healthcare systems, which would enable health-care providers to treat tobacco users routinely. • In reality, many opportunities and entry points exist in primary care to reach tobacco users and provide them with brief tobacco interventions. Therefore, the entire health system should be strengthened and should function well in order to respond adequately to these opportunities. 15 minutes Introduce the WHO Health System Framework (six building blocks) and the WHO definition of health system strengthening. Emphasize the following: • The WHO Health System Framework is a useful tool for guiding policymakers to strengthen their health systems or to build a well-functioning health system to improve the delivery of brief tobacco interventions in primary care. • The six health system building blocks identified by WHO are the content areas of health system strengthening interventions. • Policy-makers have key roles and responsibilities in changing each of the six building blocks to promote access to brief tobacco interventions. Refer to the workbook and summarize the key tasks of policy-makers in strengthening health systems. Refer to the workbook. Workbook, PowerPoint presentation Part Isimplified version-F Refer to the workbook. Refer to the workbook. Workbook, PowerPoint presentation Part Isimplified version-D
Workbook, PowerPoint presentation Part Isimplified version-E
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Facilitators’ guide for the simplified version
Time
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Practice 60 minutes Assign participants to work in small groups to brainstorm: In each of the six building blocks, what policy interventions are needed in order to strengthen their health system to promote brief tobacco interventions? Ask participants to write down their results in Worksheet 6. Evaluation 60 minutes Ask groups to present their results. Ask participants: • As a policy-maker, are you willing to take any action to strengthen your health system to improve the delivery of brief tobacco interventions? Encourage participants to give a statement and measure the political commitment by counting positive statements made by participants. Closure 20 minutes Closing remarks, evaluation. Everyone helps critique and give feedback. Anticipated response: participants express their willingness to take actions. Workbook Work in small groups to Workbook, discuss effective policy flipchart interventions in each of the six building blocks.
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PARTICIPANTS’ WORKBOOK FOR THE FULL VERSION Module 1: Treatment of tobacco dependence: a top priority for health-care systems Objectives Upon completion of this module participants will be able to: − recognize treatment of tobacco dependence as a key component of any comprehensive tobacco control programme; − list the reasons for countries to make treatment of tobacco dependence a top priority for their health systems; − state rationales for promoting access to treatment of tobacco dependence in primary care settings. Agenda 1. Treatment of tobacco dependence: a key component of any comprehensive tobacco control programme (15 minutes). 2. WHO Framework Convention on Tobacco Control (WHO FCTC) and WHO MPOWER package (15 minutes). 3. Treatment of tobacco dependence: a top priority for health systems (10 minutes). 4. Relying on the health system (10 minutes). 5. Existing effective tobacco cessation services in primary care settings (20 minutes). 6. Evaluation (20 minutes). Preparation 1. Treatment of tobacco dependence: a key component of any comprehensive tobacco control programme (20 minutes) Stories Story 1: What happened after the United Kingdom’s smoke-free legislation was introduced? Between March 2006 and July 2007 smoke-free legislation was introduced in Scotland, Wales, Northern Ireland and England, making virtually all enclosed public places and workplaces smoke-free. Although the main aim of the legislation was to protect workers from the negative consequences of second-hand smoke, the new law has also encouraged smokers to quit smoking. Local National Health Service (NHS) Stop Smoking Services in England saw an increase in demand of around 20% in the months around the law change. What does this story imply about treatment of tobacco dependence?
Story 2: What happened after the USA raised federal tobacco tax in spring 2009? In the United States of America, when the federal cigarette tax rose to $1.01 a pack with a 62-cents-a pack increase in early 2009, there was a 2 3-fold increase in calls to the quitline during the first months compared to previous years (Figure 1).
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Participants’ workbook for the full version
Figure 1. Increase in calls in quit line following rise in federal cigarette tax, United States, January-May, 2007-2009
Calls Volumes to 800-QUIT-NOW* Months January February March April May Total for January-May Total for year 2007 52,796 33,543 42,150 41,081 48,224 171,570 471,764 2008 88,797 37,082 60,065 48,810 41,852 234,754 591,659 2009 76,685 91,316 203,374 114,389 67,824 553,508 TBD
* Please note that 800-QUIT-NOW only counts calls that are relayed through the national number: About 35 states have local toll-free numbers as well, so the compiled numbers underestimate the actual calls to quitlines. Source: North American Quitline Consortium.
What does this story imply about treatment of tobacco dependence?
Story 3: Suppliers of electronic cigarettes ran out of stock in Hong Kong SAR after the 50% tobacco tax increase in 2009 On 25 February 2009, the Financial Secretary of China, Hong Kong Special Administrative Region (Hong Kong SAR), announced that the excise duty on tobacco products would be immediately increased by 50% to HK$ 24 per pack above the previous levels of just over HK$ 16 per pack in response to increasing smoking rates. Sales of electronic cigarettes soared immediately after the tax increase. A news report on 3 March 2009 said suppliers of electronic cigarettes had run out of stock. Some smokers used electronic cigarettes as an alternative to smoking tobacco cigarettes and some smokers used electronic cigarettes to quit tobacco use. However, electronic cigarettes are unproven as a product for cessation. What does this story imply about treatment of tobacco dependence?
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Participants’ workbook for the full version
Implication of the stories: Implementing population-level tobacco control policies can motivate people to stop smoking and can create demand for tobacco dependence treatment. There is a need for scaling up effective tobacco dependence treatment as part of a comprehensive tobacco control programme. Presentation 2. WHO Framework Convention on Tobacco Control (WHO FCTC) and WHO MPOWER package (15 minutes) 2.1 The provisions in the WHO FCTC Measures relating to the reduction of demand for tobacco: Article 6 Price and tax measures to reduce the demand for tobacco. Article 7 Non-price measures to reduce the demand for tobacco. Article 8 Protection from exposure to tobacco smoke. Article 9 Regulation of the contents of tobacco products. Article 10 Regulation of tobacco product disclosures. Article 11 Packaging and labelling of tobacco products. Article 12 Education, communication, training and public awareness. Article 13 Tobacco advertising, promotion and sponsorship. Article 14 Demand reduction measures concerning tobacco dependence and cessation.
Measures relating to the reduction of supply of tobacco: Article 15 Illicit trade in tobacco products. Article 16 Sales to and by minors. Article 17 Provision of support for economically viable alternative activities. 2.2 The MPOWER package To help countries fulfil their WHO FCTC obligations, WHO introduced in 2008 the MPOWER package of six evidence-based tobacco control measures that are proven to reduce tobacco use and save lives. The MPOWER package provides practical assistance with country-level implementation of the demand reduction measures of the WHO FCTC. The MPOWER measures include: Monitor tobacco use and prevention policies. Protect people from tobacco smoke. Offer help to quit tobacco use. Warn about the dangers of tobacco. Enforce bans on tobacco advertising, promotion and sponsorship. Raise taxes on tobacco. Treatment of tobacco dependence is a key component of any comprehensive tobacco control strategy, as indicated in the WHO FCTC. Article 14 of the WHO FCTC addresses the issue of treatment of tobacco dependence. Tobacco control policies are complementary. Implementing population-level tobacco control policies can motivate tobacco users to quit and can create demand for tobacco dependence treatment. On the other hand, providing support for tobacco users to quit can also help reduce their resistance to the implementation of those population-level tobacco control policies.
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Strengthening health systems for treating tobacco dependence in primary care / Part I
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3. Treatment of tobacco dependence: a top priority for health-care systems (10 minutes) Brainstorming Why should treatment of tobacco dependence be a top priority for a health system?
Possible reasons are: • Treating tobacco dependence is the best thing that a health system can do to improve smokers’ health because: − treating tobacco dependence can help save a smoker’s life (quitting at age 60, 50, 40 or 30 years gains, respectively, about 3, 6, 9 or 10 years of life expectancy); − people who quit smoking after having a heart attack reduce their chances of having another heart attack by 50%; − people with early lung cancer who quit smoking could double their chances of surviving. • Treating tobacco dependence is one of the most cost-effective among many other common reimbursed disease prevention interventions, such as the treatment of hypertension and high blood cholesterol (see Table 1) • Health concerns are the major motive for tobacco users to quit. • Effective interventions exist for treating tobacco dependence. Even a minimal intervention (less than 3 minutes) can significantly increase overall tobacco abstinence rates. • Tobacco-use screening coupled with brief interventions is one of the most valuable clinical preventive services that can be offered in medical practice on the basis of the health impact on the relevant population and the cost-effectiveness of each service. Table 1. Numbers needed to treat (NNT) to achieve certain outcomes for various interventions Intervention Statins Antihypertensive therapy Cervical cancer screening GP brief advice to stop smoking < 5 minutes GP brief advice + pharmacological support GP brief advice + pharmacological support + behavioural support Outcome Prevent one death over five years Prevent one stroke, myocardial infarction, death over one year Prevent one death over 10 years Prevent one premature death Prevent one premature death Prevent one premature death NNT 107 700 1140 80 38−56 16−40
4. Relying on the health system (10 minutes) Although treatment of tobacco dependence should be made available in a country's entire health system at all levels of service delivery, including primary, secondary and tertiary health care settings, the primary care settings should be the main focus.
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Strengthening health systems for treating tobacco dependence in primary care / Part I
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Why should we promote access to tobacco cessation services in primary care settings?
Reasons for promoting access to treatment of tobacco dependence in primary care settings: • The public health impact of an intervention/service depends on effectiveness, reach and delivery cost. The primary care setting is a less costly setting for reaching the majority of tobacco users in many countries.
Reach • The primary care staff have long and close contact with the community and are well accepted by local people. • The primary care is the primary source of health care and can reach the majority of the population in many countries. For instance: − In Brazil, 70% of the population receives free health care from the public system. − In Cuba, the national health care programme addresses the needs of over 95% of the population. − In Fiji, 70-80% of the population has access to health services. − In Thailand, the universal coverage scheme provides health care for most of the country’s 64 million people. • Primary care programmes appear to reach the poor far better than other types of health programmes do, and the poor are the ones who smoke the most (see Figure 2). Delivery cost • Resources for health will always be limited. Primary care is a route to achieving maximum possible affordable coverage of effective tobacco cessation services with available resources. For instance: − The primary care setting is less costly as the primary care approach emphasizes providing as much care as possible at the first point of contact through integrated service delivery models. − Various opportunities and entry points exist for integrating identification and treatment of tobacco users in primary care (e.g. the DOTS strategy, programmes dealing with cardiovascular disease, chronic obstructive pulmonary disease, diabetes, maternal and child health). Figure 2. Prevalence of tobacco use within countries and between countries at different levels of development Q1 28.00 26.00 24.00 22.00 20.00 18.00 16.00 14.00 12.00 10.00 Low income 32 Source: World Health Survey, 2006.
Q2
Q3
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Note: Q1-Q5: Lowest-highest income groups.
%
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Participants’ workbook for the full version
Practice 5. Existing effective tobacco dependence treatments in primary care settings (20 minutes) Pair up with the person sitting next to you to list all existing effective tobacco dependence treatment services in primary care settings in your country. Be prepared to share your list with the whole group. Use this checklist to develop your list Brief counselling from health professionals Group counselling in a clinic or community Telephone quitline Self-help materials Pharmacological treatments: nicotine replacement therapy (NRT), bupropion, and varenicline Quit and Win competitions Others
6. Evaluation (20 minutes) Please volunteer to share your list. Please provide comments on the lists of the other participants and make sure that you understand what effective tobacco cessation services are. Summary Only effective treatments are valuable for helping tobacco users. The guidelines for implementation of Article 14 of the WHO FCTC recommend that: • all Parties should aim to develop a comprehensive system to provide a range of interventions for tobacco cessation and treatment of tobacco dependence; • if they cannot do this simultaneously, Parties should at least provide brief tobacco interventions to all tobacco users. Many opportunities and entry points exist in primary care to reach tobacco users and provide them with brief tobacco intervention. If the health system does not function well, it may not be able to take full advantage of these opportunities. Therefore, in line with the Article 14 guidelines and in view of the reality of health systems in developing countries, this training will focus on assisting countries to take one of their first actions towards developing a comprehensive tobacco dependence treatment system, i.e. strengthening the health system to improve the delivery of brief tobacco interventions in primary care. 33
Strengthening health systems for treating tobacco dependence in primary care / Part I
Participants’ workbook for the full version
Module 2: WHO Health System Framework and steps for formulating policy interventions to strengthen health systems Objectives Upon completion of this module participants will be able to: − define a health system and health system strengthening; − state the functions, structure and goals of a health system; − describe WHO Health System Framework; − describe the five steps for health policy formulation (AIDE-ME); − list policy-makers’ responsibilities for strengthening health systems to promote brief tobacco interventions; − show political commitment for strengthening health systems to improve the delivery of brief tobacco interventions in primary care. Agenda 1. Quiz on health system basics (20 minutes). 2. Using the WHO Health System Framework and the results chain to understand health system basics: definition, functions and goals of a health system (20 minutes). 3. WHO definition of health system strengthening (15 minutes). 4. Five steps for health policy formulation (10 minutes). 5. The responsibilities of policy-makers (30 minutes). 6. Evaluation (20 minutes). Preparation 1. Quiz on health system basics (20 minutes) Please answer the following questions independently. (1)What is a health system? ( ) A. The publicly owned facilities that deliver personal health services. B. All organizations, people and actions whose primary intent is to promote, restore or maintain health. C. Organizations that deliver both personal and public health services. D. All organizations, people and actions whose primary intent is to treat diseases. (2)What are health system goals? ( ) A. Better health. B. Responsiveness to non-health needs. C. Fair financing. D. All of the above. (3)What is health system strengthening? ( ) A. Improving six health system building blocks and managing their interaction in ways that achieve more equitable and sustained improvements across health services and health outcomes. B. Implementing system-level changes to improve access to specific interventions for specific diseases. C. Improving the general structure and function of publicly owned facilities. D. Increasing the number and quality of the health-care workforce. Correct answers: 1: B; 2: D; 3: A.
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Participants’ workbook for the full version
Presentation 2. Using the WHO Health System Framework and the results chain to understand health system basics: definition, functions and goals of a health system (20 minutes) 2.1 WHO definition of a health system A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health. A health system is more than the pyramid of publicly owned facilities that deliver personal health services. 2.2 WHO Health System Framework The WHO Health System Framework (six building blocks framework) (see Figure 3) can help people better understand the structure, functions and goals of a health system.
2.2.1 The structure of a health system comprises: • service delivery; • the health workforce; • information support; • medical products and technologies; • financing; • leadership and governance. 2.2.2 The basic functions of a health system are: • stewardship(governance); • creating resources; • financing; • delivering services. 2.2.3 Health system goals Health systems have multiple goals. • Overall goals/outcomes of health systems are improving health and health equity in ways that are responsive, financially fair, and make the best, or most efficient, use of available resources. • Intermediate goals are greater access to and coverage of effective health interventions. Figure 3. The WHO Health System Framework System building blocks Service Delivery Health Workforce Information Medical Products, Vaccines & Technologies Financing Leadership / Governance Source: WHO Strengthening Health Systems to Improve Health Outcomes, Geneva, 2007
Overall Goals / Outcomes
Access Coverage
Improved Health (level and equity) Responsiveness Social and Financial Risk Protection
Quality Safety
Improved Efficiency
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Strengthening health systems for treating tobacco dependence in primary care / Part I
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2.2.4 Relations between functions and goals of a health system Figure 4 shows the logical links between different functions and goals of a health system. Figure 4. Multiple, dynamic relationships between the functions and goals of a health system
Functions the system performs Stewardship
Intermediate goals
Overall goals / outcomes
Creating resources
Delivering services
Access to and coverage of effective health interventions
Responsiveness (to nonmedical needs) Health Fair (financial) contribution
Financing
2.3 The results chain The results chain also can be a very useful tool to analyse a health system because it gives you a systematic view of a health system (see Figure 5). Figure 5. The results chain of a health system
Inputs and process Health workforce Governance Financing Information
Outputs
Outcomes
Impact
Service delivery: readiness, quality, safety
Access to and coverage of service and equity
Health outcomes Financial risk protection Responsiveness
Medical products and technologies Source: WHO monitoring and evaluation of health systems strengthening: an operational framework, Geneva, 2010
3. WHO definition of health system strengthening (15 minutes) No consensus exists on the operational definition of health system strengthening. WHO defines health system strengthening as: improving six health system building blocks and managing their interactions in ways that achieve more equitable and sustained improvements across health services and health outcomes. The WHO definition of health system strengthening reveals that the WHO Health System Framework can be a useful tool for strengthening health systems to deliver brief tobacco interventions because it shows practical ways to strengthen health systems by using six operational “building blocks” to: • locate, describe and classify health system constraints; • identify where and why interventions are needed; • predict the effects of health system strengthening interventions on its results.
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Strengthening health systems for treating tobacco dependence in primary care / Part I
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4. Five steps for health policy formulation The WHO Health System Framework defines six building blocks as the content areas of Health system strengthening interventions. However, it does not tell us what to do and how to do to strengthen each of the six building blocks. For the purpose of translating the six building blocks framework into health system strengthening actions at the operational level, on the basis of the six-stage Health Policy Cycle designed by Marc J Roberts et al., a five-step process (AIDE-ME) is summarized for using the WHO Health System Framework as a tool to form policy interventions to strengthen health systems for improving the delivery of brief tobacco interventions in primary care. They are as follows: Assess health systems performance. Identify the causes of poor performance. Define appropriate health system strengthening strategies. Establish and implement health systems policies. Monitoring and Evaluation. Figure 6 shows that the health policy formulation process can be viewed as a cycle of five steps/stages, namely: • assessing the current performance; • identifying its causes; • defining appropriate strategies and policies; • implementing those policies; • evaluating their consequences. The cycle then begins again, as some policies and interventions may need to be modified as the result of the findings of the Monitoring and Evaluation process. Figure 6. The steps for health policy formulation Assessing current performance
Monitoring and Evaluation Engaging all stakeholders
Identifying the causes of poor performance
Establishing and implementing policies
Defining appropriate strategies
Source: Roberts MJ, Hsiao W, Berman P, Reich MR. Getting health reform right: a guide to improving performance and equity. New York, NY, Oxford University Press. 2004
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Strengthening health systems for treating tobacco dependence in primary care / Part I
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For the rest of this training, you will be guided through each of these five steps to improve the necessary skills for health system policy changes. Practice 5. The responsibilities of policy-makers (30 minutes) Health system strengthening is a complicated process which involves all key actors of a health system, including policy-makers. Working in small groups, review each of the six building blocks, brainstorm and list key tasks that policy-makers have to take on for strengthening health systems to improve the delivery of brief tobacco interventions. Please write down your results on Worksheet 1. 6. Evaluation (20 minutes) Each group presents its lists of policy-makers’ key tasks. Table 2 summarizes the roles and responsibilities of policy-makers for strengthening health systems to improve the delivery of brief tobacco interventions and for making sure that all the following are included: health sector policies, harmonization and alignment, oversight and regulation. Table 2. The key tasks of policy-makers in strengthening health systems to improve the delivery of brief tobacco interventions Building blocks Service delivery Key tasks • Form supportive policies for integrated service delivery. • List the governance implications of different service delivery models. • Influence demand for tobacco dependence treatment. • Form national workforce policies and investment plan. • Form policy on inclusion of tobacco use in all existing medical records and in data on health services. • Develop standardized tools and instruments for recording tobacco use. • Develop national policy, guidelines and regulations on treatment of tobacco dependence. • Monitor the quality and safety of cessation tools. • Form national health financing policy. • Use effective mechanisms to ensure adequate funding for treatment of tobacco dependence. • Set appropriate policy guidance for treatment of tobacco dependence. • Promote collaboration and coalition-building. • Design an appropriate system.
Health workforce Information support
Medical products and technologies Financing
Leadership and governance
Summary Health systems strengthening is a complicated process involving all key actors of a health system. It requires both technical and political knowledge and action. Policy-makers should play key roles in strengthening health systems to improve the delivery of brief tobacco interventions. The WHO Health System Framework is a useful tool to assist policy-makers in conducting health systems strengthening activities. A five-step process (AIDE-ME) can be used to formulate and implement health policies to strengthen health systems for improving the delivery of brief tobacco interventions in primary care.
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Strengthening health systems for treating tobacco dependence in primary care / Part I
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Worksheet 1. Key tasks of policy-makers to change each of the six building blocks
Building blocks Service delivery
Key tasks
Health workforce
Information support
Medical products and technologie
Financing
Leadership and governance
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Participants’ workbook for the full version
Module 3: Assessing the performance of brief tobacco interventions in primary care Objectives Upon completion of this module participants will be able to: − define performance; − use appropriate indicators and measurement methods to assess the performance of brief tobacco interventions in primary care; − develop a plan for assessing the performance of brief tobacco interventions in primary care. Agenda 1. Defining the performance of brief tobacco interventions in primary care (15 minutes). 2. The indicators and measurement methods to assess the performance of brief tobacco interventions in primary care (30 minutes). 3. Developing a plan for assessing the performance of brief tobacco interventions in primary care (30 minutes). 4. Evaluation (30 minutes). Preparation 1. Defining the performance of brief tobacco interventions in primary care (15 minutes) Question: What is “performance”?
The term “performance” may include the entire range of components from measuring goal attainment to the efficiency of input use, and to the way the system is functioning. Here we mean how well primary care providers perform to deliver brief tobacco interventions. Presentation 2. The indicators and measurement methods to assess the performance of brief tobacco interventions in primary care (30 minutes) Assessing the performance of brief tobacco interventions in primary care require an understanding of the objective of strengthening health systems. The objective of the WHO health systems strengthening approach for treating tobacco dependence is to achieve universal coverage of brief tobacco interventions in a country, providing a brief intervention to every tobacco user at every primary care visit.
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Strengthening health systems for treating tobacco dependence in primary care / Part I
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Brainstorming According to the above objective, what indicators can be used to measure the performance of brief tobacco interventions in primary care?
Possible indicators are: Coverage: percentage of tobacco users visiting primary care settings in the last 12 months who stated that they received brief tobacco interventions. Equity in brief tobacco interventions coverage: the level of coverage for different districts, different groups (poor vs. non-poor, female vs. male.). Data sources: − clinical data; − survey. Practice 3. Developing a plan for assessing the performance of primary care providers in delivering brief tobacco interventions (30 minutes) Work in small groups to develop a plan for assessing the performance of primary care providers in delivering brief tobacco interventions in your country. The plan should consist of the following components: − indicators; − data source; − data analysis and synthesis; − data dissemination, communication and use. Please use Worksheet 2 to develop your performance assessment plan. 4. Evaluation (30 minutes) Each group presents its plan for the performance assessment. Summary Assessing the current performance of primary care providers in delivering brief tobacco interventions in your country is a starting point for the health systems strengthening process. The results of the performance assessment will be used to guide your decisions on whether or not the primary care providers’ performance need to be improved, and which performance problems you should focus on.
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Strengthening health systems for treating tobacco dependence in primary care / Part I
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Worksheet 2.
Indicators Indicator 1
Data sources
Data analysis and synthesis
Data dissemination, communication and use
Indicator 2
Indicator 3
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Strengthening health systems for treating tobacco dependence in primary care / Part I
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Module 4: Identifying the causes of poor performance Objectives Upon completion of this module participants will be able to: − discuss the principles and tools to diagnose the causes of poor performance of primary care providers in delivering brief tobacco interventions; − describe steps to identify the causes of poor performance in delivering brief tobacco interventions in primary care settings. Agenda 1. The principles and tools for identifying the causes of poor performance (15 minutes). 2. Steps for using the WHO Health System Framework to identify the causes of unsatisfactory performance in delivering brief tobacco interventions in primary care settings (20 minutes). 3. Practice using the WHO Health System Framework to identify the causes of unsatisfactory primary care providers’ performance in delivering brief tobacco interventions (40 minutes). 4. Evaluation (30 minutes). Preparation 1. The principles and tools for identifying the causes of poor performance (15 minutes) This module is about how to do a diagnosis. Definition of “diagnosis”: Diagnosis means identifying the nature or cause of some phenomenon; determining the root cause of a disease. According to this definition, this module is about identifying the causes of poor performance – that is, identifying the root causes of low coverage of brief tobacco interventions in primary care settings. Diagnostic tool In this training we recommend using the WHO Health System Framework (the six building blocks) as a tool to identify the underlying causes of poor performance of primary care providers in delivering brief tobacco interventions. Presentation 2. Steps for using the WHO Health System Framework to identify the causes of unsatisfactory performance in delivering brief tobacco interventions in primary care settings (20 minutes) The process of identifying the causes of unsatisfactory performance requires multiple steps. We have to keep asking “why” until we have discovered the root causes of the poor performance that we want to improve. The WHO Health System Framework (six building blocks) can be a good analytical tool for this process.
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Strengthening health systems for treating tobacco dependence in primary care / Part I
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Figure 7. The logical links between six building blocks and health systems performance
Inputs and process
Outputs
Outcome
Medical products, technology
Information support
Leadership and Governance
Health workforce
Primary care service delivery Cessation clinic Part of integrated Equity primary care Quitline
Poor performance
Financing
2.1 Advantages of using the WHO Health System Framework as an analytical tool Health systems are complex. Performance problems are unlikely to be caused by only one factor. There are likely to be several stages or series of causes. Figure 7 shows that the WHO Health System Framework (six building blocks) can help: − establish a link between aspects of poor performance and the causal factors in each of the six building blocks; − locate and classify the possible causes of the poor performance in delivering brief tobacco interventions that can in turn be the basis for policy interventions. 2.2 The steps for using the WHO Health System Framework as an analytical tool to identify possible causes of poor performance The diagnostic journey will work back along the results chain. The first step is to identify the possible causes of poor performance at “output” level – i.e. the possible causes in the “service delivery” block. The second and successive steps will look at each of the other five building blocks to analyse the earlier causes of these final output causes (the root causes of the poor performance). Example Consider the following example. Suppose you identified unsatisfactory performance of your primary care providers in delivering brief tobacco interventions as follows: only 30% of tobacco users with health visits in primary care settings in the last 12 months received brief tobacco interventions. Suppose you want to improve this rate by strengthening health systems. We will work through this example to see how the diagnostic process operates. The first step is to identify possible causes in the “service delivery” block (output level). Figure 8 lists three possible causes that often contribute to low coverage of brief tobacco interventions in primary care settings.
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Strengthening health systems for treating tobacco dependence in primary care / Part I
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Figure 8. Identifying causes at output level
Causes at output level Primary care facilities are not ready to deliver brief tobacco interventions Primary care providers are not willing to deliver brief tobacco interventions Tobacco users do not accept brief tobacco interventions
Performance outcome
30% of tobacco users received brief interventions
* In this and subsequent figures, the arrows point is in the direction of causation, but in the diagnostic process we should build our analysis in the opposite direction, from outcome to causes.
The second step is to move back through the results chain and look at the five building blocks at “inputs and process” level to work out what causes the situation in the “service delivery” block. In this example, we have to map out why primary care facilities are not ready to deliver brief tobacco interventions, why PRIMARY CARE providers are not willing to deliver brief tobacco interventions, and why tobacco users do not accept brief tobacco interventions. Let us select the first cause to continue the process of causal analysis. As illustrated in Figure 9, this second stage shows how a diagnostic anlaysis can identify the further causes of poor performance at inputs and process level. Is the process faulty? Are inputs insufficient? Figure 9. Identifying inputs and process-level causes of lack of readiness of primary care facilities to deliver brief tobacco interventions
Further causes at inputs and process level Leadership and governance • No guidelines on brief tobacco interventions Health workforce • Staff have not been trained in brief tobacco interventions Financing
Causes at output level
Primary care facilities are not ready to deliver brief tobacco interventions
Information support • Tobacco-use status is not included in medical records Medical products and technology • Self-help materials are not available
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Strengthening health systems for treating tobacco dependence in primary care / Part I
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The successive steps to discover further linked causes (the root causes) of the causes that we have identified at the second step. The causes that we have identifed at the second step are unlikely to be the root causes. That means that each of these causes gives rise to still further questions on “why is that?” If we think that the cause that we have identified at the second step is not a root cause of poor performance, we have to continue to look at the building blocks at inputs and process level to discover the root causes of that cause, which may require multiple steps. Figure 10 shows how to map out one further set of causual connections for “staff have not been trained in brief tobacco interventions”. The final step is to identify the root causes that can be changed by policy interventions. Identifying potentially effective changes in one or more building blocks is the end of the diagnostic task and the beginning of the policy development task. Figure 10. More steps to discover the root causes of poor performance
Root causes of poor performance at inputs and process level Leadership and governance • No policy in place requiring staff to attend the training Health workforce • No capacity to conduct training on brief tobacco interventions Financing • No financial support for training staff in brief tobacco interventions Information support Staff have not been trained in brief tobacco interventions
Medical products and technology
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Strengthening health systems for treating tobacco dependence in primary care / Part I
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Practice 3. Practise using the WHO Health System Framework to identify the causes of poor performance in delivering brief tobacco interventions (40 minutes) Please work in small groups to: 1. Select one performance problem in delivering brief tobacco interventions in your primary care settings. 2. Identify possible output-level causes (causes in the “service delivery” block) of this performance problem. 3. Select one output-level cause and use the WHO Health System Framework to discover its root causes. 4. Point out the causes that can be changed by policy interventions. Please write down your results on Worksheet 3. 4. Evaluation (30 minutes) Each group presents its results. Everyone helps critique and give feedback. Summary The diagnostic analysis of the performance problem requires multiple successive steps. The WHO Health System Framework can be helpful for this analysis. Poor performance in delivering brief tobacco interventions in primary care settings is most likely caused by several factors located in different building blocks. A health system is a set of interconnected parts with multiple relationships and interactions that must function together to be effective. Therefore, solving performance problem may well require action on more than one cause at a time – i.e. changing more than one building block. Not all causes of poor performance can be changed by health system policy interventions. Therefore, the end of the diagnostic task is to list all the causes that can be changed by health system policy interventions.
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Worksheet 3. Root cause analysis of poor performance in delivering brief tobacco interventions Performance problem Causes at output level
Root causes at input and process level Leadership and governance
Can be changed by policy interventions
Participants’ workbook for the full version
Health workforce
Strengthening health systems for treating tobacco dependence in primary care / Part I
Financing
Information support
Medical products and technologie
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Strengthening health systems for treating tobacco dependence in primary care / Part I
Participants’ workbook for the full version
Module 5: Defining appropriate health system strengthening strategies Objectives Upon completion of this module participants will be able to: − describe the advantages and disadvantages of different approaches to strengthening health systems; − discuss appropriate strategies to take advantage of existing opportunities to improve the performance of brief tobacco interventions in primary care while other programmes also benefit. Agenda 1. Review the progress of the health policy formulation journey (AIDE- ME) (15 minutes). 2. Three common approaches to strengthening health systems (30 minutes). 3. Defining appropriate strategies for strengthening health systems to improve performance of brief tobacco interventions delivery (30 minutes). 4. Evaluation (30 minutes). Preparation 1. Review the health policy formulation journey (AIDE- ME) (15 minutes) Question: Where are we now on the health policy formulation journey?
Referring to Figure 6, it is clear that we have just completed the second step “I” and have identified the changeable root causes of poor performance of the primary care providers in delivering brief tobacco interventions. We are now moving into the third step of the health policy formulation journey to define appropriate strategies to tackle the causes of poor performance – i.e. what is the appropriate way to address these causes and to improve the performance of brief tobacco interventions delivery? Different strategies will guide policy-makers to generate different policy options or responses to health system constraints. Presentation 2. Three common approaches to strengthening health systems (30 minutes) There are three common approaches to strengthening health systems, namely: − the system-wide approach (horizontal approach); − the disease/service/intervention-specific approach (vertical approach); − the matrix approach. 2.1 System-wide approach (horizontal approach) The system-wide approach focuses on strengthening the overall structure and functions of health systems to deliver a variety of services for the entire population (see Table 3). The rationale behind this approach is that, if a health system functions well, it will be able to effectively respond to all diseases and priorities. Therefore the horizontal approach to health system strengthening typically aims to tackle the root causes of failure to make the health system capable of providing comprehensive care and eventually to achieve significant long-term improvement in coverage and quality of care for all diseases and priorities (see Table 4).
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The development of “horizontal” health systems and infrastructure capable of delivering a number of services should be the goal. In the long term, horizontal systems are cost-effective. However, as illustrated in Figure 11, most developing countries have weak health systems, poor infrastructure and limited resources (funding, management structure, capacity and equipment deficiencies) which make it difficult to provide even basic services to the population in the short term. Figure 11. Illustration of the horizontal approach The “horizontal approach”
minimum level health expenditure - “the swamp” additional health expenditure - horizontal current health expenditure
2.2 Disease/service/intervention-specific approach (vertical approach) This approach focuses on specific interventions for specific disease categories or for working with specific populations (see Table 3). The vertical approach to health system strengthening tends to focus more on micro-level solutions or shorter term solutions which can lead to dramatic progress on specific diseases in the short term but may lead to only limited gains (see Table 4). Figure 12 is useful in visualizing the vertical approach, which results in fragile, isolated islands of sufficiency. Programmes dealing with tuberculosis, HIV/AIDS and malaria are typical examples of this approach. They have their own financing, management structures and staff, even down to the service delivery level. Table 3. A comparison of horizontal and vertical modes of service delivery Horizontal approach Beneficiaries Health workers Range of service Cost-effectiveness Management Sustainability Entire population Multipurpose personnel Vertical approach Specific target population Specialized personnel
Comprehensive, continuous and person-centred care Programme-defined disease control interventions Efficient use of scare funding and resources in the long term Difficult Dramatic progress on specific diseases in the short term Easy
Yes, building on existing general health infrastructure Lack of sustainability and up-scaling benefits and outcomes limited to target area and funding cycle
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2.3 Matrix approach The advantages and limitations of the vertical and horizontal approaches (see Table 5) make people believe that both need to coexist in what could be called a matrix approach. It is proposed to alleviate problems through a combination of the vertical and horizontal aspects to aid resource allocation. The features of a matrix approach to health system strengthening include: • taking the desired health outcomes as the starting point for identifying health system constraints that “stops” effective scaling up of services; • addressing health systems bottlenecks in such a way that specific health outcomes are met while system-wide effects are achieved and other programmes also benefit (strengthening health system components contributing to health outcomes across more than one disease or thematic areas); • addressing primarily health systems policy and capacity issues using both shorter-term and longterm solutions. However, the key element of a matrix approach is INTEGRATION: − integration of health-specific service delivery to ensure a continuum of preventive and curative services at the point of delivery, based on an agreed set of interventions. Integration refers to: − the links between different types of service; − the links between the community and the formal health system; − the links between the public, private and voluntary sector; − the links between levels of the health system; − the link with other sectors/social services. WHO suggests using an integrated approach to health system strengthening, emphasizing integration of brief tobacco interventions into existing primary care services because there are many opportunities and entry points in primary care to reach and provide tobacco users with brief tobacco interventions (e.g. DOTS strategy, programmes dealing with cardiovascular disease, chronic obstructive pulmonary disease, diabetes, maternal and child health). The integration approach will contribute to: − the success of treating more tobacco users and other health programmes; − continuous strengthening of health systems (the increased brief tobacco interventions delivery capacity of the primary care provider, the system-changing capacity of primary care service managers and the policy-making capacity of policy-makers will have long-term benefits for all health outcomes). Figure 12. Illustration of the vertical approach The “vertical approach”
“Island of sufficiency” minimum level health expenditure additional health island expenditure “the swamp” crumbling vertical current health expenditure
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Table 4. Typical system constraints and possible disease-specific and health system responses Constraint Financial inaccessibility: inability to pay, informal fees Physical inaccessibility: distance to facility Inappropriately skilled staff Disease-specific response Exemptions/reduced prices for focal diseases. Health system response Development of risk-pooling strategies.
Outreach for focal diseases. Continuous education and training workshops to develop skills in focal diseases.
Reconsideration of long-term plan for capital investment and siting of facilities. Review of basic medical and nursing training curricula to ensure that appropriate skills are included in basic training.
Poorly motivated staff
Financial incentives to reward delivery of particular Institution of proper performance review systems, priority services. creating greater clarity of roles and expectations regarding performance of roles, review of salary structures and promotion procedures. Continuing education and training workshops to develop skills in planning and management. Creation of special disease-focused crosssectional committees and task forces at national level. Restructuring of ministries of health, recruitment and development of a cadre of dedicated managers. Building systems of local government that incorporate representatives from health, education and agriculture, and that promote accountability of local governance structures to the people. Development of accreditation and regulation systems.
Weak planning and management Lack of intersectional action and partnership
Poor quality care among private sector providers
Training of private sector providers.
Table 5. Advantages and limitations of the horizontal and vertical approaches to health system strengthening Horizontal approach Advantages Tackle the root causes of failure and contribute to overall system strengthening. Increases the range of options, and the benefits accrue to several, not single, priorities (i.e. efficiencies are possible). Limitations Vertical approach Targeting particular health system constraints rather than taking on the whole, leading to only limited gains. Focus on shorter-term microlevel solutions, which can help maintain focus and deliver quicker return than broader system-based interventions.
The benefits take longer to accrue and the effort may When several vertical parallel subsystems are created become unfocused and unmanageable. within the broader health-care system, this may result in: – duplications; – distortions; – disruptions; – distractions.
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Practice 3. Defining appropriate strategies for strengthening health systems to improve performance of brief tobacco interventions delivery (30 minutes) Please work in small groups to define appropriate integration strategies for strengthening health systems to improve the performance of brief tobacco interventions delivery in primary care settings. Please refer to Worksheet 3 and select one pre-identified changeable root cause of poor performance in delivering brief tobacco interventions in your primary care setting for this exercise. The strategies should focus on integration, i.e. to create or to strengthen any of the following linkages: the links between different types of service; the links between the community and the formal health system; the links between the public, private and voluntary sectors; and the links between levels of the health system; the link to other sectors or social services (work across sectors). The strategies should be built on sound situation analysis, analysis of the available resources, investing in policy dialogue, coherence to other existing operational plans, ensuring monitoring and evaluation. The strategies should have a balance between short-term progress and long-term improvement in coverage of brief tobacco interventions. Please write down your results on Worksheet 4. 4. Evaluation (30 minutes) Each group presents its results. Everyone helps critique and give feedback. Summary The matrix health systems strengthening strategies/integration strategies can tackle root causes and the benefits accrue to several, not single, priorities.
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Worksheet 4.
Root causes can be changed by policy Integration strategies Policy interventions Implementation plan
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Module 6: Establishing and implementing health systems policies Objectives Upon completion of this module participants will be able to: − discuss the importance of involving interest groups in the process of policy development; − describe the strategic way to engage all stakeholders; − develop health systems policies based on predefined integration strategies; − list basic organizational tasks for effectively implementing health systems policies; − develop an implementation plan. Agenda 1. Review the process for developing a national health policy in the country (15 minutes). 2. Engaging all stakeholders in the process of policy development (25 minutes). 3. How to implement health systems policies effectively (20 minutes). 4. Practise designing a health systems policy and its implementation plan (40 minutes). 5. Evaluation (30 minutes). Preparation 1. Review the process for developing a national health policy in the country (15 minutes) Health policy can be defined as the “decisions, plans, and actions that are undertaken to achieve specific health care goals within a society”. Each country has its own process or steps to develop and implement national health policy. Question: What is the process for developing a national health policy in your country?
No matter what process you have to go through in your country, it is very important to involve interest groups in the process of policy development. Presentation 2. Engaging all stakeholders in the process of policy development (25 minutes) 2.1 The importance of engaging all relevant stakeholders Brainstorming Why is it important to involve all relevant stakeholders in the process of policy development?
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Engaging all relevant stakeholders in the process of policy development is critical for building awareness and support. Involving interest groups in the process of policy development serves at least five functions: • It allows policy-makers to hear and take into account interest groups’ concerns. Awareness of such concerns can improve a policy’s chances of successful implementation. • It increases the acceptance of a policy, because it increases the psychological and physical legitimacy of the process that developed it. • It educates interest groups about the concerns of, and pressures exerted on policy-makers by, other constituencies. • It educates the participants about the details of the policy that ultimately emerge – i.e. what it means for their own responsibilities. • It receives authorization and support from the highest political levels. Without authorization and support at high level it is unlikely that the process of policy development will be workable (senior management can create the climate for serious and effective policy work). This is particularly important for the treatment of tobacco dependence because in many countries so far it has not been given the high priority it deserves at both provincial and national levels. However, policy-makers should lead the process. Participation by all relevant stakeholders can improve a policy substantially and can have a major impact on its acceptability, but it can also get out of hand and make the life of a policy-maker extremely difficult. Therefore, the process of policy development needs to be managed strategically, and policy-makers should lead any participatory process of policy development. 2.2 Who are the relevant stakeholders? Stakeholders are persons or groups who are directly or indirectly affected by a project, as well as those who may have interests in a project and/or the ability to influence its outcome, either positively or negatively. Brainstorming Who are the relevant stakeholders we need to engage to scale up brief tobacco interventions in primary care settings?
The key stakeholders for scaling up brief tobacco interventions in primary care settings may include: − senior policy-makers or managers such as ministers of health; − actors in other sectors; − NGOs; − academics; − health service managers; − health-care providers; − community leaders. 56
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2.3 How to engage with relevant stakeholders Brainstorming What are appropriate strategies for engaging with relevant stakeholders?
Stakeholder engagement strategies and activities can be decided on the basis of a stakeholder’s position on the influence/interest grid (Figure 13). Figure 13. Influence/interest grid for stakeholder prioritization
High
Influence
Low Low Interest High
Below are examples of strategies and actions for different stakeholders: • High influence, interested people: you should fully engage and make the greatest efforts to satisfy them. • High influence, less interested people: put enough work in with these people to keep them satisfied, but not so much that they become bored with your message. • Low influence, interested people: keep these people adequately informed, and talk to them to ensure that no major concerns arise. • Low influence, less interested people: monitor these people, but do not bore them with excessive communication. 3. How to implement health systems policies effectively (20 minutes) Good policies are worth little if they cannot be implemented. 3.1 Basic organizational tasks for implementing health systems policies effectively The basic organizational tasks are as follows: • Develop an implementation plan. • Assemble a team to carry out the plan and assign tasks to them. • Devise and coordinate schedules.
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3.2 Implementation plan Sound implementation planning is a key element in ensuring the successful delivery of health systems policies. An implementation plan should include the following key components: • Broad interest groups and relevant stakeholders involvement for implementation at national and subnational levels and coordination with the country political and institutional cycles. This can promote advocacy and activism within communities to lobby for implementation of new health systems policy because collaboration with partners can improve implementation efforts. • Identify resources and draw up a budget plan (to ensure adequate financial and non-financial resources for the implementation of the new policy). • Policy dialogue (the new policy needs to be clearly communicated) • Build capacity and ensure coherence between the national health policy and other existing programs (the new policy will require new skills for people working in health systems: health service managers should be given training in how to implement and manage the policy, and primary care providers should be given training in new skills). • Design a monitoring and evaluation system with nationally agreed indicators and a minimum dataset that balances costs against data quality (this component can help strengthen implementation capacity because the monitoring process will be able to provide information to implementers and the wider public). Monitoring and evaluation is discussed in detail in Module 7. Practice 4. Practise designing a health systems policy and its implementation plan (40 minutes) Please work in small groups to: • design a health systems policy to change a pre-identified root cause of poor performance in delivering brief tobacco interventions, following Worksheet 4 and using the strategies generated during Module 5 (please make sure that your integration policy interventions build on existing opportunities such as existing networks/partnerships, existing health programmes and existing mechanisms); • develop a one-year implementation plan for implementing the health systems policy. Please make sure that your implementation plan includes: • a clear step-by-step task timetable; • the administrative structure to carry out the plan; • an action plan for each of the key tasks, including − involving interest groups and relevant stakeholders, − resources and budget, − policy dialogue, − capacity-building and coordination with other existing programs, − monitoring and evaluation (see Module 7 ); Please write down your one-year implementation plan using the template below. 5. Evaluation (30 minutes) Each group presents its results. Everyone helps critique and give feedback. Summary It is critical to engage all stakeholders in the process of policy development and implementation, but policy-makers should play the leadership role.
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Developing health systems policy should take advantage of existing opportunities and promote integration. Developing a sound implementation plan is a key element in ensuring the successful implementation of health systems policy. In order to organize this work into manageable steps, a one-year implementation plan with annual updating is recommended.
IMPLEMENTATION PLAN TEMPLATE A. Description of the health systems policy a. Please describe what kind of decisions and actions will be undertaken to improve the performance of primary care providers in delivering brief tobacco interventions. b. Please outline the policy objective in SMART terms: Specific Measurable Achievable Relevant Time-framed. B. Action steps for different tasks a. Involving interest groups and relevant stakeholders Activities Locus of responsibility Time frame Expected outcome Resource requirements Non-financial resources 1 2 3 4 Budget
b. Policy dialogue Activities Locus of responsibility Time frame Expected outcome Resource requirements Non-financial resources 1 2 3 4 Budget
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c. Capacity-building Activities Locus of responsibility Time frame Expected outcome Resource requirements Non-financial resources 1 2 3 4 Budget
d. Monitoring and evaluation (to be completed in Module 7)
Module 7: Monitoring and Evaluation Objectives Upon completion of this module participants will be able to: − define monitoring and evaluation (M&E); − describe the components of the operational framework for M&E of health systems strengthening policy interventions; − conduct M&E activities; − develop an M&E plan for monitoring and evaluation of health systems strengthening policy interventions for improving the coverage of brief tobacco interventions. Agenda 1. Definition and purpose of M&E (30 minutes). 2. The operational framework for monitoring and evaluation of health systems strengthening policy interventions (20 minutes). 3. How to conduct M&E activities (15 minutes). 4. Developing an M&E plan (40 minutes). 5. Evaluation (30 minutes). Preparation 1. Definition and purpose of M&E (30 minutes) 1.1 Brainstorming What is monitoring? What is evaluation? Why do we need M&E?
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Please refer to Table 6 for the definition and comparison of monitoring and evaluation. Please note that, even though monitoring and evaluation are different, the methods used can often be similar and there is overlap between the two processes. Therefore, monitoring and evaluation are usually talked about as one set of related activities and are commonly referred to as M&E. 1.2 Why do you need M&E for your health systems strengthening? • Monitoring progress and evaluating results are key steps of any policy implementation (the components of policy implementation are discussed in Module 6). • M&E shows whether a policy/service is accomplishing its goals. M&E identifies programme weaknesses and strengths, areas of the programme that need revision, and areas of the programme that meet or exceed expectations. Table 6. A comparison of monitoring and evaluation Monitoring Definition The periodic collection and review of information on project implementation for comparison with implementation plans. Evaluation A process of data collection designed to assess the effectiveness of a project in attaining its preset objectives, and the extent to which observed changes are attributable to the project. To measure whether and to what extent the project’s originally stated objectives have been achieved. Assessing data at critical stages of the project implementation. Sense of achievement.
Purpose
To determine how well a project is being implemented at different levels, at what cost. Collecting data on progress.
Focus
Sense of completion Time focus Periodicity
Sense of progress.
Present. An ongoing activity during the life of the project.
Past-future. Done at the end of the project but could be planned at strategic periods during the life of the project in the form of reviews (e.g. mid-term, or biennial reviews). To judge the impact of a project or a policy on the target population and to help design the next policy/project.
How is the information used? Output processing
To solve problems and to improve project implementation now and in the future.
Progress indicators needs to be closely monitored by a few people.
Evaluation results need to be discussed, processed and interpreted by all stakeholders.
Presentation 2. The operational framework for monitoring and evaluation of health systems strengthening policy interventions (20 minutes) In order to develop an M&E plan we need an operational framework. WHO recommends a common framework based on the results chain, named the “Results Framework” for monitoring progress and evaluating performance in health system strengthening actions. The Results Framework for health system strengthening M&E is actually a chart. The results chain is its horizontal axis and the M&E activity is its vertical axis (see Figure 14). 61
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The horizontal axis of the framework shows how health inputs are reflected in outputs, outcomes and impact. The health systems strengthening efforts should lead to measurable changes in each of the four steps of the results chain. M&E should measure all of these changes, namely: − inputs and processes such as human and financial resources, supportive policies and partnerships; − outputs such as level and distribution of brief tobacco interventions delivery; − outcomes such as coverage of brief tobacco interventions; − impact such as improved health levels and equity. The vertical axis of the framework addresses four M&E activities, namely: − indicator selection; − data collection; − analysis and synthesis practices (including quality assessment); − communication and use of the results for decision-making. Figure 14. Monitoring and evaluation of health systems strengthening
Inputs and process
Outputs
Outcomes
Impact
Infrastructure/ICT Governance Health workforce Supply chain Information Financing
Indicator domains
Intervention access and services readiness Intervention quality, safety and efficiency
Coverage of intervention Prevalence risk behaviours and factors
Improved health outcomes and equity Social and financial risk protection Responsiveness
Administrative sources Data collection Financial tracking system; NHA Databases and records: HR, infrastructure, medecines etc. Policy data
Facility assessments
Population-based surveys Coverage, health status, equity, risk protection, responsiveness
Facility reporting systems Service readiness, quality, coverage, health status
Vital registration Analysis & synthesis Communication & use
Data quality assessment; Estimates and projections; Use of research results; Assessment of progress and performance; Evaluation Targeted and comprehensive reporting; Regular country review processes; Global reporting Source: WHO monitoring and evaluation of health systems strengthening: an operational framework.
3. How to conduct M&E activities (15 minutes) There are four steps to conducting M&E activities for health systems strengthening policy interventions: 1) Identify a comprehensive list of core indicators that capture all steps of the results chain. 2) Identify associated data sources for each indicator. 3) Analyse and synthesize data using the core indicators and targets. 4) Translate the data into information relevant for decision-making. 62
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The Results Framework outlines useful information or recommendations for conducting each of the four M&E activities across the results chain (see Table 7). Table 7. Useful information or recommendations for conducting M&E activities Indicators Comprises four major indicator domains: • system inputs and processes; • outputs; • outcomes; • impact. System inputs, processes and outputs reflect health systems capacity. Outputs, outcomes and impact are the results of investments and reflect health systems performance. Recommends preferred and alternative data sources for each block of indicators. Outlines needed tools for data quality assurance, synthesis and analysis, with a focus on building country-level capacities. Addresses the importance of dissemination, communication and use of the monitoring and evaluation results to inform policy-making at all levels.
Data sources Data analysis and synthesis
Data dissemination and communication
Practice 4. Developing an M&E plan (40 minutes) To conduct the above-mentioned M&E activities effectively, we need to develop a comprehensive action plan for monitoring and evaluation as an integral part of the whole policy implementation plan, as discussed in Module 6. Please work in small groups, following Worksheet 4, to continue developing an M&E plan for monitoring and evaluation of your designed policy intervention (practice activity in Module 6) for improving the coverage of brief tobacco interventions. Make sure that your action plan for monitoring and evaluation covers all M&E activities: indicator selection, data collection, analysis and synthesis practices, and communication and use of the results for decision-making. Please write your M&E plan on Worksheet 5. 5. Evaluation (30 minutes) Each group presents its results. Everyone helps critique and give feedback. Summary M&E is an integral part of the implementation process of health systems strengthening policies. Evaluation of the performance of health systems in delivering brief tobacco interventions requires a solid M&E system. The M&E plan should build on the country health systems surveillance (CHeSS) platform if it exists. Please remember that you should take action to actually implement your designed policies following your implementation plan. Otherwise, they are meaningless.
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Worksheet 5. M&E action plan
Indicators Data sources Participants’ workbook for the full version
Analysis and synthesis
Dissemination and communication for decision-making
Indicator 1
Indicator 2
Strengthening health systems for treating tobacco dependence in primary care / Part I
Indicator 3
Indicator 4
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PARTICIPANTS’ WORKBOOK FOR THE SIMPLIFIED VERSION
Objectives Upon completion of this module participants will be able to: − acknowledge their obligations under the WHO FCTC to support tobacco users to quit as part of any comprehensive tobacco control programme; − list the reasons for making treatment of tobacco dependence a top priority for their health-care systems; − describe the content areas of health system strengthening interventions: the six health system building blocks identified by WHO; − show political commitment for strengthening health systems to improve the delivery of brief tobacco interventions. Agenda 1. Current situation of tobacco use and tobacco control in the country (25 minutes). 2. The Parties’ obligations under the WHO FCTC to support tobacco users to quit (15 minutes). 3. What a country can do to support tobacco users to quit, and how (15 minutes). 4. Prioritizing tobacco dependence treatment in primary care (15 minutes). 5. The need to strengthen health systems to promote brief tobacco interventions (15 minutes). 6. WHO Health System Framework: a tool for strengthening health systems (15 minutes). 7. Practise using the WHO Health System Framework to identify effective policy interventions to promote brief tobacco interventions (60 minutes). 8. Your commitment to strengthening health systems to improve the delivery of brief tobacco interventions (60 minutes). Preparation 1. Current situation of tobacco use and tobacco control in the country (25 minutes) Brainstorming What is the current prevalence of tobacco use in your country? What are the current tobacco control efforts in your country?
Please find recent information about tobacco prevalence and the implementation of tobacco control measures, including treatment of tobacco dependence in your country. The information is available through the online WHO tobacco control country profile generated from data collected for the WHO report on the global tobacco epidemic, 2011: warning about the dangers of tobacco: http://www.who.int/tobacco/surveillance/policy/country_profile/en/ Please find the estimated numbers and proportions of deaths attributable to tobacco in your country recently in the WHO global report: mortality attributable to tobacco, 2012, which is available at: http://whqlibdoc.who.int/publications/2012/9789241564434_eng.pdf According to the above-mentioned WHO data, you will see that tobacco use is a big public health problem in your country and that urgent action is needed to reduce tobacco use by fully implementing the WHO FCTC.
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Presentation 2. The Parties’ obligations under the WHO FCTC to support tobacco users to quit (15 minutes) 2.1 The provisions in the WHO FCTC The WHO FCTC obligates Parties to implement comprehensive tobacco control measures to reverse the global tobacco epidemic. Below are the core provisions in WHO FCTC:
Measures relating to the reduction of demand for tobacco: Article 6 Price and tax measures to reduce the demand for tobacco. Article 7 Non-price measures to reduce the demand for tobacco. Article 8 Protection from exposure to tobacco smoke. Article 9 Regulation of the contents of tobacco products. Article 10 Regulation of tobacco product disclosures. Article 11 Packaging and labelling of tobacco products. Article 12 Education, communication, training and public awareness. Article 13 Tobacco advertising, promotion and sponsorship. Article 14 Demand reduction measures concerning tobacco dependence and cessation. Measures relating to the reduction of the supply of tobacco: Article 15 Illicit trade in tobacco products. Article 16 Sales to and by minors. Article 17 Provision of support for economically viable alternative activities. Treatment of tobacco dependence is a key component of any comprehensive tobacco control strategy, as indicated in the WHO FCTC (Article 14 of the WHO FCTC addresses the issue of treatment of tobacco dependence). 2.2 Tobacco control interventions are complementary Implementing population-level tobacco control policies – e.g. increasing tobacco taxes, banning smoking in public places and educating about the dangers of tobacco – can motivate tobacco users to quit and can create demand for tobacco dependence treatment. Here are some examples: • In England, introduction of smoke-free legislation resulted in a 20% increase in demand for local National Health Service (NHS) Stop Smoking Services. • In the United States of America, federal tobacco tax increase resulted in a 2−3 fold increase in calls to the quitline. • In Canada, introduction of graphic warning labels made 67% of smokers want to quit. On the other hand, providing support for tobacco users to quit can help reduce their resistance to the implementation of population-level tobacco control policies. 3. What a country can do to support tobacco users to quit, and how (15 minutes) 3.1 What does a country need to do to support tobacco users to quit? Guidelines for implementation of Article 14 of the WHO FCTC recommend that: • all Parties should aim to develop a treatment system to provide the fullest complement of interventions for tobacco cessation and treatment of tobacco dependence. 3.2 How does a country develop a tobacco dependence treatment system? Guidelines for implementation of Article 14 of the WHO FCTC recommend that: • Parties should use a stepwise approach to developing their tobacco dependence treatment, and should start by integrating brief tobacco interventions into primary care services.
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In this way, a country can develop its tobacco dependence treatment as rapidly as possible and at as low a cost as possible because integrating brief tobacco intervention into primary care services has the potential to: − reach more than 80% of all tobacco users per year; − trigger 40% of case to make a quit attempt; − help 2−3% of those receiving brief advice quit successfully; − form a promising referral source and create demand for more intensive tobacco cessation services such as quitlines and specialized tobacco dependence treatments. 4. Prioritizing tobacco dependence treatment in primary care (15 minutes) 4.1 Treating tobacco dependence is the best thing that health system can do to improve health for all At individual level: helping smokers quit at age 60, 50, 40 or 30 years gains, respectively, about 3, 6, 9 or 10 years of life expectancy. At population level: • Supporting current tobacco users to quit synergistically with other tobacco control measures can bring about immediate changes in prevalence rates and tobacco-related death and disease because the short- to medium-term tobacco-related death and disease are due to its current users. • It was estimated that if adult tobacco consumption were to decrease by 50% by the year 2020, about one third of global tobacco-related deaths could be avoided (see figure 15). 4.2 Treating tobacco dependence is one of the most cost-effective among other common medical interventions Table 1 shows that treating tobacco dependence is more cost-effective than many other common reimbursed disease prevention interventions, such as the treatment of hypertension and high blood cholesterol. Therefore, governments concerned with health gains in the short- to medium-term should consider encouraging adults to quit and making treatment of tobacco dependence a top priority for the healthcare system. Figure 15. Estimated cumulative tobacco deaths 1950-2050 with different intervention strategies 520 500 500 Baseline If proportion of young adults taking up smoking halves by 2020 If adults consumption halves by 2020 220 200 190 100
400 Tobacco deaths (millions) 340 300
70
0 1950
2000
Year
2025
2050 67
Curbing the epidemic: governments and the economics of tobacco control (Development in Practice Series). Washington, DC, The World Bank, 1999.
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5. The need to strengthen health systems to promote brief tobacco interventions (15 minutes) Despite the evidence on the effectiveness and cost-effectiveness of tobacco dependence treatments, they are scarce in low- and middle-income countries where health-care providers do not routinely carry out even brief tobacco interventions. In general, less than 50% of primary care providers routinely ask and advise all patients to quit. • In developed countries, a multicentre study across 12 European countries found that, overall, only 36% of health professionals reported always advising patients to quit smoking. • In developing countries, primary care provider’s performance in 5As delivery is likely to be even lower. For example, a study has documented that only 12.9% of the patients were asked about tobacco use, and 11.9% of tobacco users reported being advised against tobacco use during the current visit in South African primary care settings. The main reasons for poor performance of brief tobacco interventions include: − health-care providers’ lack of knowledge and training on treatment of tobacco dependence; − lack of integration of tobacco dependence treatment into health-care systes to enable health-care providers to treat tobacco users routinely. However, primary care is an ideal place to identify and treat tobacco users. The public health impact of an intervention/service depends on effectiveness, reach and delivery cost. The primary care system can help reach the majority of tobacco users in many countries. Below are some countries' population coverage of primary care services • In Brazil, 70% of the population receives free health care from the public system. • In Cuba, the national health care programme addresses the needs of over 95% of the population. • In Fiji, 70–80% of the population have access to health services. • Thailand’s universal coverage scheme provides health care for most of its 64 million people. The primary care system can also help reduce the delivery cost by integrating brief tobacco intervention into primary care services. Many opportunities and entry points exist in primary care systems to reach and provide tobacco users with brief tobacco interventions, such as: − the DOTS strategy; − programmes dealing with cardiovascular disease, chronic obstructive pulmonary disease, diabetes, maternal and child health. Therefore, we need to strengthen our primary care services and make the whole health system function well in order to respond adequately to such opportunities, ensuring that tobacco users at least receive brief tobacco interventions. 6. WHO Health System Framework: a tool for strengthening health systems (15 minutes) 6.1 WHO Health System Framework The WHO Health System Framework (six building blocks framework) (see Figure 3) can help people better understand what a health system is and what constitutes health systems strengthening. This Framework defines a discrete number of “building blocks” that make up the system (the structure of a health system). They are: − service delivery; − health workforce; − information support; − medical products and technologies; − financing; − leadership and governance.
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6.2 WHO definition of health system strengthening Based on the WHO Health System Framework, WHO defines “health system strengthening” as “improving six health system building blocks and managing their interactions in ways that achieve more equitable and sustained improvements across health services and health outcomes”. The WHO definition of health system strengthening reveals that: • The WHO Health System Framework can be a useful tool for strengthening health systems to improve the performance of brief tobacco interventions delivery because it shows practical ways to strengthen health systems by using six operational “building blocks” to: − locate, describe and classify health system constraints; − identify where and why policy interventions are needed; − predict the effects of health system strengthening intervention on its results. • The six health system building blocks are the content areas of health system strengthening interventions. As powerful actors in a health system, policy-makers have key roles and responsibilities in changing each of the six building blocks. Table 2 summarizes the key tasks of policy-makers in strengthening health systems to improve the delivery of brief tobacco interventions. Practice 7. Practise using the WHO Health System Framework to identify effective policy interventions to promote brief tobacco interventions (60 minutes) Work in small groups, review each of the six building blocks and brainstorm: • In each of the six building blocks, what policy interventions are needed in order to strengthen your health system to improve the delivery of brief tobacco interventions? Please write down your results on Worksheet 6. Evaluation 8. Your commitment to strengthening health systems to improve the delivery of brief tobacco interventions (60 minutes) Each group presents its list of effective policy interventions. Please help provide your comments on the other groups' lists and make sure that you understand what the effective policy interventions are to promote brief tobacco interventions in your health system. Please actively express your opinion on the following: • As a policy-maker, are you willing to design and implement those effective policies to improve the delivery of brief tobacco interventions? Summary Governments concerned with health gains in the short- to medium-term should consider making treatment of tobacco dependence a top priority for health-care system. Starting with integrating brief tobacco interventions into primary care is the quickest and most efficient way towards developing a country's comprehensive tobacco dependence treatment system, as recommended by guidelines for implementation of Article 14 of the WHO FCTC. Many opportunities and entry points exist in primary care to reach tobacco users and provide them with brief tobacco interventions. If the health system does not function well, it may not be able to take full advantage of such opportunities. Therefore, policy-makers should play key roles in strengthening health systems to improve the delivery of brief tobacco interventions in primary care using the WHO Health System Framework as a practical tool.
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Worksheet 6. Policy interventions for changing each of the six building blocks
Building blocks Service delivery
Effective policy interventions
Health workforce
Information support
Medical products and technologies
Financing
Leadership and governance
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38. Revised draft of the WHO Global Action Plan for the Prevention and Control of NCDs (2013–2020). (http://www.who.int/nmh/events/2013/revised_draft_ncd_action_plan.pdf, accessed 13 March 2013). 39. Health system strengthening improving support to policy dialogue around national health policies, strategies and plans. Sixty-fourth World Health Assembly, World Health Organization, 2011. (http://apps.who.int/gb/ebwha/pdf_files/WHA64/A64_12-en.pdf, accessed 8 April 2013). 40. A Framework for national health policies, strategies and plans, Geneva, World Health Organization, 2010. (http://www.who.int/hiv/topics/ppm/framework_nhpsp.pdf, accessed 8 April 2013). 41. Systems thinking for health systems strengthening. Geneva,World Health Organization, 2009. (http://whqlibdoc.who.int/publications/2009/9789241563895_eng.pdf, accessed 4 April 2013).
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Appendix: Sample evaluation form
APPENDIX: SAMPLE EVALUATION FORM Please select the answer you most agree with. Please also give your written feedback in the space provided. 1. Overall I found the training workshop useful for my work Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 2. Which part of the training workshop did you find the most useful?
3. Which part of the training workshop did you find the least useful?
4. The workshop facilitator had a good knowledge of the subject Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 5. The workshop facilitator’s skills in conveying the subject matter were good Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 6. As a result of my participation in the training workshop, I feel more confident to develop and implement health systems policy for promoting tobacco dependence treatment Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 74
Strengthening health systems for treating tobacco dependence in primary care / Part I
Appendix: Sample evaluation form
7. How difficult did you find the training workshop? Too difficult Difficult Just right Easy Too easy 8. How could the workshop implementation be improved?
9. How could the training materials be improved?
10. Overall, how would you rate the workshop? Very good Good Average Poor Very poor 11. Any other comment, suggestion, criticism:
Thank you for your feedback!
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For further information, kindly contact PND as follows: Prevention of Noncommunicable Diseases (PND) World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland Tel.: + 41 22 791 21 11 Fax: + 41 22 791 48 32 Email: pnd@who.int http://www.who.int/tobacco/en/
WHO Library Cataloguing-in-Publication Data Strengthening health systems for treating tobacco dependence in primary care. Contents: Part I: Training for policy-makers: developing and implementing health systems policy to improve the delivery of brief tobacco interventions; Part II: Training for primary care service managers: planning and implementing system changes to support the delivery of brief tobacco interventions; Part III: Training for primary care providers: brief tobacco interventions; Part IV: Training for future trainers: applying adult education skills to training. 1.Tobacco use disorder - prevention and control. 2.Smoking - prevention and control. 3.Smoking cessation. 4.Primary health care. 5.Delivery of health care. 6.Capacity building. 7.Teaching materials. I.World Health Organization. ISBN 978 92 4 150541 3 (NLM classification: HD 9130.6)
© World Health Organization 2013 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int ) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int ). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/copyright_form/en/index.html ). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in France
Strengthening health systems for treating tobacco dependence in primary care Part III: Training for primary care providers: Brief tobacco interventions
Strengthening health systems for treating tobacco dependence in primary care / Part III
Contents
CONTENTS
Part III: Training for primary care providers: Brief tobacco interventions ............................................. 3 Introduction.................................................................................................................................................. 3 Facilitators’ guide ...................................................................................................................................... Module 1: The role of primary care providers in tobacco control and tobacco dependence treatment........................................................................................... Module 2: Basics of tobacco use and tobacco dependence............................................................... Module 3: Overview of brief tobacco interventions.............................................................................. Module 4: Asking, advising and assessing readiness to quit............................................................. Module 5: Dealing with low motivation ................................................................................................. Module 6: Assisting and arranging for follow-up ................................................................................ Module 7: Addressing non-smokers’ exposure to second-hand smoke .......................................... Module 8: Introduction to pharmacotherapy ....................................................................................... Module 9: Promoting brief tobacco interventions in the community................................................ Participants’ workbook ............................................................................................................................. Module 1: The role of primary care providers in tobacco control and tobacco dependence treatment........................................................................................... Module 2: Basics of tobacco use and tobacco dependence ................................................................. Module 3: Overview of brief tobacco interventions................................................................................ Module 4: Asking, advising and assessing readiness to quit............................................................. Module 5: Dealing with low motivation ................................................................................................. Module 6: Assisting and arranging for follow-up ................................................................................ Module 7: Addressing non-smokers’ exposure to second-hand smoke .......................................... Module 8: Introduction to pharmacotherapy ....................................................................................... Module 9: Promoting brief tobacco interventions in the community................................................ 8 8 9 10 11 13 14 16 17 18 20 20 24 35 39 43 48 52 55 62
References and resources ......................................................................................................................... 64 Appendix: Sample evaluation form ....................................................................................................... 67
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PART III: TRAINING FOR PRIMARY CARE PROVIDERS: BRIEF TOBACCO INTERVENTIONS
INTRODUCTION Primary care providers have several roles to play in tobacco control, including preventing non-tobacco users from starting to use, assisting tobacco users in quitting, and protecting non-tobacco users from exposure to tobacco smoke. This part of the training focuses on their roles as clinicians in helping tobacco users quit. Despite the evidence on the effectiveness and cost-effectiveness of brief tobacco interventions, more than 50% of primary care providers, especially those in low- and middle-income countries, do not routinely deliver these interventions. The lack of knowledge and skills about tobacco and tobacco control is a major barrier to the provision of brief tobacco interventions. The Global Health Professions Student Survey (GHPSS) data showed that, while 90% of the health professions students have a desire to receive formal training in patient counselling, less than 33% of them have actually received such training. The purpose of Part III is to improve primary care providers’ knowledge, skills and confidence to: − routinely identify tobacco users and provide brief tobacco interventions to assist them in quitting; − educate every non-tobacco user seen in a primary care setting about the dangers of second-hand smoke and help them avoid exposure to second-hand smoke. LEARNING OBJECTIVES, SKILL DEVELOPMENT AND OUTCOMES Learning objectives Upon completion of this training participants will be able to: − explain the role of primary care providers in tobacco control and tobacco dependence treatment; − describe prevalence and patterns of tobacco use in their country; − explain the health, social and economic consequence of tobacco use and benefits of quitting; − explain the biological, psycho-behavioural and social causes of tobacco dependence; − list existing effective tobacco dependence treatment methods; − describe and deliver brief interventions to assist tobacco users routinely in quitting according to a 5A’s model and a 5R’s model; − describe and deliver a brief intervention to help non-tobacco users avoid exposure to second-hand smoke according to a 5A’s model; − apply tools to assess tobacco users’ levels of nicotine dependence; − list effective tobacco cessation medications and appropriately prescribe nicotine replacement therapy (NRT) products. Skills developed 1. Ability to apply the knowledge of tobacco use and its harmful effects. 2. Ability to use the 5A’s brief intervention model to assist tobacco users who are willing to quit in making a quit attempt. 3. Ability to use the 5R’s brief intervention model to motivate tobacco users who are unwilling to quit to make a quit attempt. 4. Ability to use the 5A’s brief intervention model to help non-tobacco users avoid exposure to secondhand smoke. 5. Ability to advise on effective tobacco cessation medications and to appropriately prescribe NRT products.
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Training for primary care providers
Outcomes 1. Primary care providers become competent in routinely delivering brief tobacco interventions to help tobacco users quit. 2. Primary care providers become competent in routinely delivering brief tobacco interventions to protect non-tobacco users from tobacco smoke. STRUCTURE AND CONTENT The training for primary care providers consists of nine modules. These nine modules are designed to train primary care providers with knowledge, skills and effective intervention models for delivering brief interventions to help both tobacco users and non-tobacco users in primary care settings (see Figure 1). Figure 1. Algorithm for delivering brief tobacco interventions
YES Advise in a clear, strong and personalized manner. Module 4
Ask: do you use tobacco? Module 4
NO Ask: does anyone else smoke around you? Module 7
YES Assess: if the patient is ready to quit? Module 4 Help avoid exposure to second-hand smoke. Module 7
NO Encourage continued abstinence.
YES Assist and Arrange. Module 6
NO Promote motivation to quit (5Rs). Module 5
Each of the nine training modules is presented in a four-step format: preparation, presentation, practice and evaluation. The modules are summarized below. Further guidance for facilitators follows in the detailed Facilitators’ guide. Module 1: Module 2: Module 3: Module 4: Module 5: Module 6: Module 7: Module 8: Module 9: The role of primary care providers in tobacco control and tobacco dependence treatment. Basics of tobacco use and tobacco dependence. Overview of brief tobacco interventions. Asking, advising and assessing readiness to quit. Dealing with low motivation. Assisting and arranging for follow-up. Addressing non-smokers’ exposure to second-hand smoke. Introduction to pharmacotherapy. Promoting brief tobacco interventions in the community.
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Training for primary care providers
If all nine modules are used, the duration of the training workshop is 2.5 days. However, the duration and detail covered in each module should be adapted to the needs of the participants. Their needs will depend on their experience and knowledge of the issue, the availability of intensive tobacco dependence treatments, the pattern of tobacco use in the country, and the infrastructure of their health system. A sample agenda for the training workshop of 2.5 days is provided below. Day 1 8:30 – 9:00 9:00 – 9:30 9:30 − 9:50 9:50 − 10:30 10:30 − 10:45 10:45 − 12:00 12:00 − 13:00 13:00 − 14:40 14:40 − 15:00 15:00 − 16:30 16:30 − 17:00 Day 2 8:30 – 9:00 9:00 − 10:45 10:45 − 11:00 11:00 − 12:45 12:45 − 13:45 13:45 − 15:30 15:30 − 15:45 15:45 − 17:05 17:05 − 17:30 Day 3 8:30 – 9:00 9:00 − 11:00 11:00 − 11:15 11:15 − 12:30 Interactive discussions Module 8: Introduction of pharmacotherapy Coffee break Closing session Workshop evaluation Interactive discussions Module 4: Asking, advising and assessing readiness to quit Coffee break Module 5: Dealing with low motivation Lunch Module 6: Assisting and arranging for follow-up Coffee break Module 7: Addressing non-smokers’ exposure to second-hand smoke Daily wrap-up Registration Welcome and Workshop Overview Participant introductions Pre-course assessment Module 1: The role of primary care providers in tobacco control and tobacco dependence treatment (1) Coffee break Module 1: The role of primary care providers in tobacco control and tobacco dependence treatment (2) Lunch Module 2: Basics of tobacco use and tobacco dependence Coffee break Module 3: Overview of brief tobacco interventions Daily wrap-up
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Training for primary care providers
PREPARING FOR THE TRAINING Organizing a training workshop requires many practical considerations to be addressed, such as when and where the training will be provided, forming a facilitation team, setting up a workshop programme and agenda, selecting participants, and logistics and materials. The facilitation team The training should be delivered by an expert facilitation team identified by the organizer in consultation with key local partners. The team should include: − a lead facilitator with detailed expertise in treatment of tobacco dependence and experience in facilitating workshops; − one or two additional facilitators with expertise in one or more aspects of tobacco control, tobacco dependence treatment and medical education; − additional content presenters as necessary. The facilitation team should be supported by one or more logistics assistants to facilitate logistical needs during the workshop, including production and reproduction of materials. Workshop programme and schedule Prior to the training, the organizer and facilitators should gather as much information as possible about the country situation and the knowledge, skills and needs of participants in order to determine the training content and structure. If necessary, adjustments can be made to the content and structure to suit the situation. The organizer and facilitators will then need to design an appropriate training schedule or agenda based on the content they want to offer to the participants, the time needed for each module and the overall timeframe of the workshop. Please try to avoid creating an overcrowded schedule during the planning of the schedule. Selecting participants The workshop is targeted at those who are providing health care services in primary care centres or in the community. They could be general practitioners, nurses, pharmacists or laboratory technicians. It is recommended that the workshop be conducted with a maximum of 30 participants.
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Training for primary care providers
Logistics The workshop requires standard meeting/training tools and facilities, namely: − one main meeting room, with participants seated around small tables in small groups; − one or two additional break-out rooms if the large room cannot accommodate small group discussions; − flipcharts and markers (one for each small group); − projector and screen for presentations; − laptop computer with speakers for presentations; − presenter’s microphone; − portable microphones for discussions (optional); − desktop computer, printer and photocopier for document production during the workshop (optional). Materials All the workshop training and background materials are provided online by WHO. These include: − the Facilitators’ guide; − presentations; − the Participants’ workbook; − workshop evaluation forms (see Appendix for sample evaluation form). The Reference and Resource section contains hyperlinks to the relevant materials needed throughout the workshop. In addition to online materials, each participant should receive a binder or folder with key printed materials, particularly: − handouts of presentations; − key resource documents for each theme. The facilitation team should decide which resources are most relevant to the participants and should include them in the printed materials. The facilitation team should also ensure that key materials are available in the language of the participants.
7
FACILITATORS’ GUIDE Module 1: The role of primary care providers in tobacco control and tobacco dependence treatment Duration Objectives 1hour 50 minutes Upon completion of this module, participants will be able to: − acknowledge their roles in tobacco control and tobacco dependence treatment; − describe the purpose of this training course; − describe existing effective tobacco dependence treatment methods; − describe the definition, effectiveness, feasibility and content of brief tobacco interventions.
Time
Facilitator activity
Participant activity
Audiovisual
Preparation 35 minutes State that tobacco use is the single most preventable cause of death in the world today, and that we as health-care providers must do our utmost to fight against tobacco. Ask participants to brainstorm: What is the role of health professionals in tobacco control and tobacco dependence treatment? Brainstorm possible roles that health professionals can play in tobacco control and Write responses on a flipchart page or whiteboard. tobacco dependence Use PowerPoint slides to describe eight key roles of health professionals treatment. in tobacco control and tobacco dependence treatment, namely: − role model; Refer to the workbook. − clinician; − educator; − scientist; − leader; − opinion-builder; − alliance-builder; − watching out for tobacco industry activities. Emphasize that this training course will focus on improving their knowledge, skills and confidence to play their role as clinician to assist smokers in quitting (to address tobacco dependence as part of their standard care practice). Presentation 30 minutes State that primary care providers are in a unique position to help tobacco users quit because: • Primary care providers have a long and close contact with the community and are well accepted by local people. • The primary care is the primary source of health care and can reach the majority of the population, especially those living in rural areas. Facilitate discussion about: What tobacco dependence treatment methods Refer to the workbook and participate in the can you use to help tobacco users? discussion. Write responses on flipchart paper or whiteboard. Refer participants to the workbook and use PowerPoint slides to explain that: • Various effective treatment methods exist. • More intensive or longer-lasting treatments are more likely to help tobacco users quit successfully. • Health-care providers can help patients quit tobacco successfully by offering brief tobacco interventions as short as three minutes. For instance: − describe the definition of brief advice used in the WHO FCTC Article 14 guidelines; − emphasize that a brief tobacco intervention is an opportunistic intervention; − show the effectiveness of brief advice on quitting. 8
Workbook, flipchart/ whiteboard, PowerPoint presentation Part IIIModule 1-A
Workbook, flipchart/whiteboard, PowerPoint presentation Part IIIModule 1-B
Anticipated response: participants list all effective treatment methods.
Anticipated response: Summarize that helping patients quit tobacco as part of routine practice takes participants agree with primary care providers only a few minutes and it is feasible, effective and efficient. this statement.
Strengthening health systems for treating tobacco dependence in primary care / Part III
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Practice 25 minutes Evaluation 20 minutes Reconvene and ask the participants to share their lists Invite comments from the participants and conclude that all they need to do to assist tobacco users to quit within 3−5 minutes can be summarized as 5A’s: Ask, Advise, Assess, Assist, Arrange. Emphasize that, during the rest of the training, participants will learn knowledge and skills to implement the 5A’s brief interventions. Group discussion. Everyone provide comments. Flipchart or whiteboard, PowerPoint presentation Part IIIModule 1-C Ask participants to pair up with the person sitting next to them to list Group discussion. what things they can do within 3 to 5 minutes to help tobacco users quit Workbook
Module 2: Basics of tobacco use and tobacco dependence Duration Objectives 1hour 40 minutes Upon completion of this module participants will be able to: − identify patterns of tobacco use (local, national, international); − describe the health, social and economic impact of tobacco use on tobacco users and others; − clarify common misconceptions held by tobacco users; − explain the benefits of quitting tobacco use; − describe why people smoke and why they don’t stop. Facilitator activity Participant activity Audiovisual
Time
Preparation 10 minutes Ask participants: In order to effectively help tobacco users quit, what do they need to know about tobacco use and tobacco dependence? Emphasize that health-care providers should have some basic knowledge of tobacco use and tobacco dependence in order to assist patients in quitting more effectively. Tell participants that, in this module, they will have an opportunity to learn about the impact of tobacco use; the benefits of quitting tobacco use; the local, national and international patterns of tobacco use; and why people smoke and do not quit. Presentation 20 minutes Ask participants: what is the impact of tobacco use on tobacco users and others? Flipchart/ whiteboard Workbook, Highlight facts and misconceptions. PowerPoint Continue to ask the group for views on the benefits of quitting tobacco use. presentation Refer to the workbook Part IIIReinforce findings with fact sheet. and participate in group Module 2-A Expand group discussion to consider health and non-health benefits. discussion and practical exercise. Give an overview of local, national, worldwide patterns of tobacco use. Ask participants what impacts these trends have. Don’t forget to include positive milestones (if any) (e.g. a smoking ban in public places). Refer to the workbook. Workbook, PowerPoint presentation Part IIIModule 2-B 9
Open group discussion. Flipchart/ Anticipate responses: whiteboard participants mention the impact of tobacco use, the benefits of quitting tobacco use, and why people smoke and do not quit.
Discuss/identify medical, social and economic impact of tobacco use.
10 minutes
Strengthening health systems for treating tobacco dependence in primary care / Part III
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Presentation 25 minutes Ask the group for ideas on why people smoke but do not quit? Anticipated responses include nicotine Prompt for personal experiences as well as professional ones. addiction, stress, Present theory and evidence on the three elements of tobacco addiction: boredom and social − physical/physiological dependence; pressure (e.g. to fit in − emotional/psychological connection; with friends). − habitual and social connection. Show a video on why quitting tobacco is so hard. Leave two or three minutes for brief Q&A at the end. Practice 20 minutes Ask the participants to discuss with the person sitting next to them two Work in pairs to list two ways in which they should use the knowledge of tobacco addiction when items. delivering brief interventions. Feedback and questions. Flipchart/ whiteboard, Workbook, video, PowerPoint presentation Part IIIModule 2-C
Evaluation 15 minutes Ask the group to reconvene and invite volunteers to read out their responses. Offer comments and invite other participants to provide feedback on responses. Read out responses and comment on each other’s responses. Anticipated responses include: showing empathy, creating a feeling of being listened to rather than lectured, and using the information coming from the patient on why they smoke to generate quitting solutions and strategies. Flipchart/ whiteboard
Module 3: Overview of brief tobacco interventions Duration Objectives 1hour 30 minutes Upon completion of this module participants will be able to: − describe the purpose and population impact of a brief tobacco intervention; − describe at least three brief tobacco intervention models; − role-play the 5A’s brief tobacco intervention model. Facilitator activity Participant activity Audiovisual
Time
Preparation 15 minutes Ask participants for their experiences of talking to patients about tobacco use. Tell participants that in this training they will have an opportunity to discuss how to talk effectively to patients about tobacco use and how to give advice in brief contacts (conducting brief tobacco interventions). Anticipated responses Flipchart/ include those based whiteboard on participants’ own responses (e.g. frustration) as professionals, as well as on the apparent responses of the patient (e.g. resistance).
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Presentation 30 minutes Present information on brief tobacco interventions: • The primary purpose of a brief tobacco intervention is to encourage tobacco users to make a quit attempt. • The population impact of a brief tobacco intervention can be clinically significant if the intervention/service is delivered routinely and widely. • There are several structured brief tobacco intervention models that can guide primary care providers through the right process to talk to patients about tobacco use and deliver advice, such as the 5A’s, 5R’s, AAR, AAA, and ABC. Workbook, Power Point presentation Part IIIModule 3-A
Practice 30 minutes Begin by suggesting role play and the benefit of scenario practice. Volunteer participants Select two volunteers to role-play a brief intervention in front of the group: will conduct the • One will be a doctor who attempts to address the patient’s smoking. role play as other participants observe. • The other will be a forty-ish male satisfied smoker who is not especially keen to stop. Simulation
Evaluation 15 minutes Congratulate volunteers on their participation! Invite to feedback and questions. Reinforce the need for practice and assure participants that there are other opportunities during training. State that, for the rest of the course, participants will learn and practise 5A’s and 5R’s brief tobacco intervention models. Participant feedback. Anticipate uncertainty in confidently handling responses. Flipchart/ whiteboard
Module 4. Asking, advising and assessing readiness to quit Duration Objectives 2 hours 5 minutes Upon completion of this module participants will be able to: − ask and advise patients about their tobacco use in an appropriate way; − use two ways to assess patients’ readiness to quit Facilitator activity Participant activity Audiovisual
Time
Preparation 15 minutes Ask participants for their thoughts on giving advice. For instance, how Anticipated responses does giving advice on clinical issues (e.g. “you have asthma”) differ from include: giving advice on behaviour change (e.g. “you need to quit smoking”)? primary care providers feel more knowledgeable and confident to give advice on clinical issues, and that giving advice on behaviour change requires new skills and strategies. Ask participants for their thoughts on how we can tell if someone is ready to quit. Inform participants that, in this module, they will discuss and practise the first three steps of the 5A’s model: Ask, Advise and Assess. Anticipated responses include those highlighting both importance and confidence as factors in motivation. Flipchart/ whiteboard
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Presentation 10 minutes Present information on how to ask about tobacco use. Make sure to include the following key points: • Ask about tobacco use at EVERY encounter. • Keep it simple: − Do you use tobacco? − Does anyone else smoke around you? • Document tobacco use status in the medical record Reinforce that: • Asking and recording tobacco use status is the first, but important, step towards helping patients stop tobacco use. • Health facilities should make a system change in order to support health-care providers by including tobacco use status in medical records as a vital sign. 20 minutes Present the theory of why advice should be personalized and how to tailor advice for a particular patient. Tell participants that they will have an opportunity to practise tailoring advice to patients later on. 20 minutes Present theories of motivation (when is someone ready to quit?) and how to assess readiness to quit. Make sure to include the following key points: • To be ready to quit, people need to believe two things: − “I want to be a non-tobacco user”; − “I have a chance of quitting successfully”. • We can then ask two questions to assess the readiness to quit: − “Would you like to be a non-tobacco user?” − “Do you think you have a chance of quitting successfully?” • An answer of “yes” to the first question and an answer of “yes” or “unsure” to the second question indicate that the tobacco user is READY to quit. • A more simple way to assess the readiness to quit is to ask just one question: − “Would you like to quit tobacco within the next 30 days?” Suggest that participants use the two-question method to assess the readiness to quit in this course because it will help them get more information from the patient to conduct appropriate motivational interventions if the patient is not ready to quit. Practice 40 minutes Practise tailoring advice. One participant will vol- Flipchart/ unteer to play the role whiteboard, The facilitator adopts the role of three fictional smokers. Each smoker of the practitioner. He or role play will differ as to demographic background, health status, family and she will: social circumstances, and beliefs about smoking. − ask about the Before each role play the fictional smoker (played by the facilitator) will patient’s smoking; introduce himself or herself: − give some tailored 1. Hamid: “I am a 57-year-old man with 10 grandchildren. I have a heart advice. condition and breathing problems.” For Hamid, advice 2. Lisa: “I am a 25-year-old woman and I have just married. We hope should refer to health, to have a large family but we do struggle financially.” longer life and passive smoking of children. For Lisa, advice should refer to fertility and the financial impact of smoking. 12
Refer to the workbook.
Workbook, PowerPoint presentation Part IIIModule 4-A
Refer to the workbook.
Workbook, PowerPoint presentation Part IIIModule 4-B Workbook, PowerPoint presentation Part IIIModule 4-C
Refer to the workbook.
Strengthening health systems for treating tobacco dependence in primary care / Part III
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Practice 3. Mustafa. “I am a man aged 35.” Mustafa does not give Flipchart/ much information. The whiteboard, volunteer will need to role play recognize this and should ask Mustafa “What do you not like about being a smoker?” Once Mustafa answers, the volunteer should give advice tailored to the issue raised.
Evaluation 20 minutes Invite the group to give critique and comments on the role plays. Feedback and questions
Module 5: Dealing with low motivation Duration Objectives 1 hour 30 minutes Upon completion of this module participants will be able to: − describe the 5R’s brief tobacco intervention model; − respond appropriately to exhibited stop-smoking resistance, employing the 5R’s model; − respond appropriately in cases of low motivation to quit, using motivational tools.
Time
Facilitator activity
Participant activity
Audiovisual
Preparation 15 minutes Ask participants for their ideas on: − what motivation is; − experiences of dealing with tobacco users who are not willing to quit. Share understandings about motivation and experiences of helping tobacco users who are Use PowerPoint slides to explain the definition of motivation in general and the definition of intrinsic motivation (a state of readiness to change). not willing to quit. This is the key predicator of behaviour change. State that participants will learn in this module how to work with patients with low motivation to quit tobacco use. Presentation 15 minutes Present the overview of the 5R’s approach and where it should be inserted during a brief intervention. Use examples to explain the delivery of the 5R’s. Tell participants that they will have an opportunity to practise delivering 5R’s interventions later on. 15 minutes Explain that, in addition to talking with tobacco users, health-care providers can also use some motivational tools to motivate patients for quitting tobacco use. Introduce four types of tool for motivating patients, namely: − cost calculators; − photos of smoking-exacerbated facial ageing; − the carbon monoxide (CO) monitor; − risk charts. Refer to the workbook. Refer to the workbook. Flipchart/ whiteboard, PowerPoint presentation Part IIIModule 5-B Flipchart/ whiteboard, PowerPoint presentation Part IIIModule 5-C Flipchart/ whiteboard, PowerPoint presentation Part IIIModule 5-A
Examine the tools and give comments on the advantages and disadvantages of each tool and whether they Ask participants to give comments on the advantages and disadvantages would be available. Feedback and of each tool, and whether this tool would be available to them. questions. Leave two or three minutes for brief Q&A at the end.
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Practice 30 minutes Practise delivering 5R’s interventions. Invite two volunteers to play the role of two practitioners who assess two fictional smokers’ readiness to quit. The facilitator will adopt the role of the two fictional smokers. Each smoker will differ in his or her response when assessed for readiness to quit. 1. Hamid: “My smoking isn’t really a concern to me.” 2. Lisa: “I want to be a non-smoker but I could never quit – I’m very addicted.” Complete the Assess questions appropriately in each case to indicate non-readiness to quit. In role play, Hamid should express concern about heart disease, while Lisa should express concern about her stress level while quitting. Evaluation 15 minutes Invite the group to give critique and comments on the role plays. Feedback and questions. For each smoker a Workbook (different) participant will assess readiness to quit (using assessment forms). They will then deliver the 5R’s if appropriate. For Hamid, the 5R’s should be delivered, focusing on risks and rewards. For Lisa, the 5R’s should be delivered, focusing on roadblocks.
Module 6: Assisting and arranging for follow-up Duration Objectives 2 hours Upon completion of this module participants will be able to: − assist patients to stop tobacco use by helping them with a quit plan and providing intra-treatment social support and supplementary materials; − arrange follow-up contacts; − arrange a referral to specialist services if available; − deliver a full, brief tobacco intervention according to the 5A’s and 5R’s models.
Time
Facilitator activity
Participant activity
Audiovisual
Preparation 15 minutes Ask participants for their thoughts on (if they were tobacco users) what kind of assistance they would need from the doctor to make a quit attempt. Anticipated responses include developing a quit plan, dealing with withdrawal symptoms, social support, and pharmacotherapy recommendations. Flipchart/ whiteboard
Presentation 20 minutes Present information on how to assist patients in making a quit attempt. Emphasize that, for the patient willing to quit, the following actions can be taken to aid him/her in quitting: • Help develop a quit plan. Strategies for this can be summarized by the acronym STAR: − Set a quit date; − Tell family, friends and coworkers about quitting; − Anticipate challenges to the upcoming quit attempt; − Remove tobacco products from your environment. Refer to the workbook. Flipchart/ whiteboard, PowerPoint presentation Part IIIModule 6-A
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Presentation • Provide practical counselling to deal with challenges or difficulties while quitting and invite the group to answer the following questions asked by patients: − What if I still have cravings? − What if I smoke after quitting? Facilitator provides suggested answers. • Provide intra-treatment social support. • Recommend pharmacotherapy if appropriate. • Provide supplementary materials: − Ask the group to list locally-available self-help materials. − Point out the limitations of self-help materials and that they should not take the place of face-to-face support. 15 minutes Present information on arranging follow-up contacts for the patient: when, how and what? PowerPoint presentation Part IIIModule 6-B Refer to the workbook. One volunteer participant to play the role of Hamid. All participants provide comments and advice. PowerPoint presentation Part IIIModule 6-C Demonstration Refer to the workbook.
25 minutes
Review each stage of the 5A’s and 5R’s models Demonstrate the full brief tobacco intervention: • Invite one participant to role-play a patient named Hamid (The participant may develop the character and dialogue as he or she wishes). − Hamid is a 57-year-old man with 10 grandchildren who has a heart condition and breathing problems. At the moment, he is not particularly concerned about his smoking. • The facilitator will take the role of a primary care provider to deliver a full, brief intervention. The facilitator will pause at each stage to get comments and advice from the group on how to proceed.
Practice 30 minutes Begin by asking participants about their current level of confidence in relation to delivering a brief intervention. Address expressions of poor confidence by referring to the evidence for the intervention, and tell them they will become confident about delivering the intervention once they have done it several times in a real situation (i.e. the need for practice). Select two pairs of volunteers to role-play a brief intervention in front of the group (two “primary care providers” and two “patients”). The “patients” will be given brief notes on their character: 1. Hamid: a 57-year-old man with a large family. He has breathing and heart problems. He is not concerned about his smoking. He is unsure about whether he could quit if he tried. 2. Lisa: a 25-year-old woman who is soon to marry. She wants to have a family. She wants to quit but is convinced that she can’t. Refer to the workbook. Anticipated responses include expressions of low confidence. The source of this poor confidence may vary. Participants may have poor confidence in: − themselves; − the intervention; − their patients. The volunteer participants will conduct the role plays (starting with Hamid). Workbook
Pause the role plays occasionally to make comments or give advice. Throughout, the importance of keeping to the 5A’s and the 5R’s structure Other participants should watch the role should be emphasized. plays and make notes. Evaluation 15 minutes Congratulations should be given to the volunteers for their courage. Give constructive, and wherever possible, positive and confidencebuilding feedback. Reinforce again how confidence will come with daily practice.
Participants may make comments.
Flipchart/ whiteboard
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Facilitators’ guide
Module 7: Addressing non-smokers’ exposure to second-hand smoke Duration Objectives 1 hour 20 minutes Upon completion of this module participants will be able to: − describe the definition and dangers of second-hand smoke; − describe the brief intervention model for reducing non-smokers’ exposure to second-hand smoke; − role-play the brief intervention to address non-smokers’ exposure to second-hand smoke.
Time
Facilitator activity
Participant activity
Audiovisual
Preparation 15 minutes State that: • Second-hand smoke exposure causes serious health problems in children and adult non-smokers. • In addition to supporting the comprehensive smoke-free laws in workplaces and public places, and supporting smokers to quit, healthcare providers should also educate every non-smoker seen in a primary care setting about the dangers of second-hand smoke and help them avoid exposure to second-hand smoke. Ask participants: Anticipated responses • Is second-hand smoke exposure common in your country? include that second• How many people are exposed to second-hand smoke in your country? hand smoke exposure is common in their Write responses on the flipchart or whiteboard. country and a high proExplain that participants will discuss how to offer a brief intervention portion of non-smokers to help non-smoking patients and their families to avoid exposure to in their country are second-hand smoke in this module. exposed to second-hand smoke. Presentation 30 minutes Ask participants to brainstorm: • What is second-hand smoke? • What diseases are known to be caused by second-hand smoke? Write responses on the flipchart or whiteboard. Present the definition of second-hand smoke and refer participants to Figure 2 to summarize diseases caused by second-hand smoke. State that participants can use the 5A’s model to offer a brief intervention to educate non-smokers about the dangers of second-hand smoke and advise them on avoiding the effects of second-hand smoke. Use examples to explain the 5A’s model for addressing second-hand smoke in brief contacts: Ask if the patient is exposed to second-hand smoke and record the response. Advise the patient to avoid exposure to second-hand smoke. Assess the patient’s willingness to reduce exposure to second-hand smoke. Assist the patient in making an attempt to make his/her daily life environment smoke-free. Arrange follow-up for the patient to obtain support and talk about the matter again. Emphasize that, in order to support health-care providers to routinely help non-smokers avoid the effect of second-hand smoke, health facilities should include second-hand smoke exposure status in medical records as well. Refer to the workbook. Participate in the discussion and provide ideas. Workbook, flipchart/ whiteboard, Power Point presentation Part IIIModule 7-A Flipchart/ whiteboard
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Practice 20 minutes Select two volunteers to role-play the 5A’s model to address non-smokers’ exposure to second-hand smoke in front of the group: • One will be a doctor who attempts to address the patient’s second-hand smoke exposure. • The other will be a newly married woman whose husband smokes at home. Volunteer participants Simulation will conduct the role play as other participants observe.
Evaluation 15 minutes Congratulate volunteers on their participation! Invite feedback and questions. Reinforce the need for practice and reassure participants that they will become confident about delivering the intervention with daily practice. Participants provide feedback. Anticipate uncertainty in confidently offering the brief intervention to address second-hand smoke. Flipchart/ whiteboard
Module 8: Introduction to pharmacotherapy Duration Objectives 2 hours Upon completion of this module participants will be able to: − describe effective tobacco cessation medications; − prescribe the available range of NRT products; − recommend bupropion and varenicline; − apply tools to assess tobacco users’ levels of nicotine dependence. Facilitator activity Participant activity Audiovisual
Time
Preparation 15 minutes Ask group to brainstorm: What effective tobacco cessation products are currently available for tobacco users? Write participants’ responses on a flipchart page or whiteboard. Use PowerPoint slides to summarize the two categories of medication (nicotine replacement medications and non-nicotine medications) that are currently available for treating tobacco dependence. Participate in the discussion and brainstorm currently available effective tobacco cessation medications. Flipchart/ whiteboard, Power Point presentation Part IIIModule 8-A
Anticipated response includes NRT products, State that, in this module, participants will have an opportunity to discuss bupropion and those tobacco cessation medications, with the focus on NRT products. varenicline. Presentation 25 minutes Present the following information for NRT (nicotine gum, transdermal patch, lozenge, oral inhaler and nasal spray), bupropion and varenicline: − what those medications are; − the purpose of using those medications; − available dosage; − advantages and disadvantages; − who can use those medications; − general guidelines for using those medications; − side-effects and warnings. Refer to the workbook.
Workbook, Power Point presentation Part IIIModule 8-B
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Presentation 15 minutes State that participants need to assess tobacco users’ levels of nicotine dependence before they actually prescribe or recommend dosage of NRT to tobacco users. Present information on how to assess the level of nicotine dependence: • Method 1: The Fagerström Test is the standard instrument for assessing the intensity of physical addiction to nicotine. • Method 2: Ask two simple questions: − How many cigarettes do you smoke per day? − At what time do you smoke your first cigarette in the morning? 15 minutes Guide participants to review the instructions for use and the dosing recommendations for each NRT product based on the level of nicotine dependence. Leave 2−3 minutes for brief Q&A at the end. Practice 30 minutes Assign participants to work in small groups to recommend NRT treatment plans for two fictional smokers: 1. Kate is a 55-year-old married female who has smoked two packs per day for the past 40 years. 2. Jack is a 35-year-old male who has smoked approximately 15 cigarettes per day for the past 20 years. Review the two case Case studies studies and work in small groups to practise prescribing NRT products for Kate and Jack. Refer to the workbook. Refer to the workbook. Workbook, Power Point presentation Part IIIModule 8-C
Feedback and questions.
Workbook, Power Point presentation Part IIIModule 8-D
Evaluation 20 minutes Invite each group to present its NRT treatment plans for Kate and Jack by writing them on a flipchart or whiteboard. Facilitator prompts discussion by sharing pre-prepared NRT treatment plans. Every one adds to the discussion and gives feedback. Flipchart/ whiteboard Workbook
Module 9: Promoting brief tobacco interventions in the community Duration Objectives 1 hour 10 minutes Upon completion of this module participants will be able to: − identify outreach opportunities for delivery of brief tobacco interventions to tobacco users in their homes or community settings; − identify referral resources within a local community for the primary care provider to deliver brief tobacco interventions.
Time
Facilitator activity
Participant activity
Audiovisual
Preparation 15 minutes Emphasize that primary care providers should use every encounter in Refer to the workbook. both clinical and community settings to provide brief tobacco interventions to all patients to quit tobacco use. Flipchart/ whiteboard, Power Point Ask participants to brainstorm about the opportunity to deliver brief Brainstorm the opportu- presentation Part IIItobacco interventions in patients’ homes and in the community. nity to deliver brief Module 9-A tobacco interventions Write responses on the flipchart or whiteboard. in patient’ homes and Emphasize that primary care providers should take all of those opportunities in the community. to deliver brief tobacco interventions to patients and their families.
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Presentation 15 minutes State that the community also has many existing resources to support primary care providers in delivering brief tobacco interventions to tobacco users. Make sure to explain the following key points: • Many community resources could be referral resources for primary care providers when they deliver brief interventions. For example: − tobacco quitlines; − specialist services in cessation clinics; − local tobacco cessation classes and support groups; − smokers’ web-based assistance; − free self-help materials. • With available community resources to provide in-depth assistance and follow-up, primary care providers will be freed up to focus on identifying and motivating tobacco users to quit using a simplified brief tobacco intervention model called AAR (Ask, Advise, Refer). Emphasize that a list of existing referral resources in the community that the primary care providers serve will be a useful tool or resource to assist the providers in delivering brief tobacco interventions. Practice 20 minutes Assign participants to small groups to compile a list of available resources for tobacco dependence treatment in their communities. Work in small groups to compile a list of existing resources. Refer to the workbook. Flipchart/ whiteboard, Power Point presentation Part IIIModule 9-B
Evaluation 20 minutes Invite each group to share its list of available community resources. Everyone adds to the Conclude that the lists can help primary care providers complement and discussion and gives feedback. extend their brief tobacco interventions by referring patients to those resources. Flipchart/ whiteboard
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PARTICIPANTS’ WORKBOOK Module 1: The role of primary care providers in tobacco control and tobacco dependence treatment Objectives Upon completion of this module participants will be able to: − acknowledge their roles in tobacco control and tobacco dependence treatment; − describe the purpose of this training course; − describe existing effective tobacco dependence treatment methods; − describe the definition, effectiveness, feasibility and content of brief tobacco interventions. Agenda 1. The role of health professionals in tobacco control and tobacco dependence treatment (35 minutes). 2. The unique position of primary care providers in helping tobacco users (10 minutes). 3. Effective tobacco dependence treatment methods (10 minutes). 4. Definition, effectiveness and feasibility of brief tobacco interventions (10 minutes). 5. The content of brief tobacco interventions (25 minutes). 6. Evaluation (20 minutes). Preparation 1. The role of health professionals in tobacco control and tobacco dependence treatment (35 minutes) Tobacco use is the single most preventable cause of death in the world today. We as health-care providers must do our utmost to fight against tobacco. Brainstorming What is the role of health professionals in tobacco control and tobacco dependence treatment?
Health professionals such as physicians, nurses, midwives, pharmacists, dentists, physiologists, chiropractors and other health-related professionals have eight key roles to play in tobacco control and tobacco dependence treatment. These roles include: • Role model: In community and clinical settings, health professionals are expected to be role models for the rest of the population, and particularly regarding tobacco. • Clinician: All health professionals in the everyday health-care setting need to address tobacco dependence as part of their standard of care practice. • Educator: Health professionals can play an important role in teaching medical students about tobacco and cessation techniques. • Scientist: All health professionals should be aware of science-based information about how tobacco control measures can be implemented within their scope of practice. • Leader: Health professionals in positions of leadership can get involved in the policy-making process, supporting comprehensive tobacco control measures that go beyond the availability of cessation. • Opinion-builder: As a citizen of a community or member of a national association for health professionals, health professionals have great potential to build opinion in support of tobacco control.
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Participants’ workbook
• Alliance-builder: Health professionals should consider cooperation with others to support tobacco control in one way or another. • Watching out for tobacco industry activities: Health professionals, as individuals or associations, have a duty to denounce tobacco industry strategies aimed at hindering local, national or international tobacco control efforts and to demand from the authorities the adoption of policies that prioritize the health and quality of life of their people over the industry’s profits. Summary Health professionals have several roles in common to play in comprehensive tobacco control efforts, namely: − preventing non-users from starting to use tobacco; − assisting tobacco users in quitting; − protecting non-tobacco users from exposure to tobacco smoke. This training course will focus on their role as clinician to assist tobacco users in quitting as part of their standard of care practice. Presentation 2. The unique position of primary care providers in helping tobacco users (10 minutes) • Primary care staff have a long and close contact with the community and are well accepted by local people. • The primary care is the primary source of health care and primary care providers can reach the majority of the population in many countries: − In Brazil, 70% of the population receives free health care from the public system. − In Cuba, the national health care programme addresses the needs of over 95% of the population. − In Fiji, 70–80% of the population has access to health services. − In Thailand, the universal coverage scheme provides health care for most of the country’s 64 million people. • Primary care programmes appear to reach the poor far better than other types of health programmes and the poor are the ones who smoke the most. 3. Effective tobacco dependence treatment methods (10 minutes) Question What tobacco dependence treatment methods can you use to help tobacco users?
There are various effective treatment methods or interventions (Table1).
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Participants’ workbook
Table 1. Summary of effectiveness data for smoking cessation interventions (abstinence at least six months) based on the latest Cochrane Reviews Intervention Quit rate (%) Comparator Odds ratio (95% confidence interval) 1.21(1.05−1.39) 1.66(1.42−1.94) 1.84(1.60−2.13) 1.37(1.20−1.56) 1.28(1.18−1.38) 1.39(1.2 −1.57) 1.98(1.60−2.46) 1.37(1.26−1.50) 1.29(1.20−1.38) Increased chances of quitting successfully 21% 66% 84% 37% 28% 39% 98% 37% 29%
Self-help interventions Physician advice
No intervention Brief advice vs. no advice Intensive advice vs. no advice Intensive vs. minimal
Nursing intervention Individual behavioural counselling Group behaviour therapy Telephone counselling
Usual care Minimal behavioural intervention Self-help programme Without telephone counselling Less intensive vs. no
Quit and Win contests Nicotine replacement therapy (NRT) Bupropion Varenicline Cytisine Clonidine Nortriptyline
8-20%
Baseline community quit rate at the 12-month assessment Placebo or non-NRT Placebo Placebo Placebo Placebo Placebo 1.58(1.50−1.66) 1.69(1.53−1.85) 2.27(2.02−2.55) 3.98(2.01−7.87) 1.63 (1.22−2.18) 2.03(1.48−2.78) 58% 69% 127% 298% 63% 103%
More intensive or longer-lasting treatments are more likely to help tobacco users quit successfully. Health-care providers can help patients quit tobacco successfully by offering brief tobacco interventions as short as three minutes (Table 2). Table 2. Meta-analysis: efficacy of, and estimated abstinence rates for, various intensity levels of person-to-person contact (n = 43 studies) Level of contact Number of arms 30 19 16 55 Estimated odds ratio (95% C.I.) 1.0 1.3 (1.01–1.6) 1.6 (1.2–2.0) 2.3 (2.0–2.7) Estimated abstinence rate (95% C.I.) 10.9 13.4 (10.9–16.1) 16.0 (12.8–19.2) 22.1 (19.4–24.7)
No contact Minimal counselling (< 3 minutes) Low intensity counselling (3−10 minutes) Higher intensity counselling (> 10 minutes)
Source: Fiore MC et al. Treating tobacco use and dependence: 2008 update. Clinical practice guideline, 2008
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Participants’ workbook
4. Definition, effectiveness and feasibility of brief tobacco interventions (10 minutes) Brief tobacco interventions, also often called “brief advice”, have been defined in the guidelines for implementation of Article 14 of the WHO FCTC as “advice to stop using tobacco, usually taking only a few minutes, given to all tobacco users, usually during the course of a routine consultation or interaction”. Brief tobacco interventions as part of routine practice are opportunistic interventions, which are feasible and resource-efficient ways of helping tobacco users quit. As shown in Table 2, a three-minute brief intervention has been shown to increase abstinence rates significantly by 30% compared to no advice. Summary Helping patients quit tobacco as part of their routine practice takes health-care providers only a few minutes and is feasible, effective and efficient. Practice 5. The content of brief tobacco interventions (25 minutes) Pair up with the person sitting next to you to list what things you can do within 3−5 minutes to help tobacco users quit. Be prepared to share your list of activities in the whole group.
6. Evaluation (20 minutes) Please volunteer to share your list of activities that can be done within 3−5 minutes to support tobacco users to quit. Please help provide your comments on the other participants’ lists and make sure that you understand what the content areas of a brief tobacco intervention are. Summary All we need to do to assist tobacco users to quit within 3−5 minutes can be summarized as 5A’s: Ask, Advise, Assess, Assist, and Arrange. These are the content areas of a brief tobacco intervention. During the rest of the training, you will learn knowledge and skills to implement the 5A’s brief interventions.
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Participants’ workbook
Module 2: Basics of tobacco use and tobacco dependence Objectives Upon completion of this module participants will be able to: − identify patterns of tobacco use (local, national, international); − describe the health, social and economic impact of tobacco use on tobacco users and others; − clarify common misconceptions held by tobacco users; − explain the benefits of quitting tobacco use; − describe why people smoke and why they don’t stop. Agenda 1. What do we need to know on tobacco use and tobacco dependence? (10 minutes). 2. The impact of tobacco use on tobacco users and others (10 minutes). 3. The benefits of quitting tobacco use (10 minutes). 4. Overview of local, national and worldwide patterns of tobacco use (10 minutes). 5. Why people smoke and do not quit (25 minutes). 6. Applying the knowledge of tobacco addiction to deliver brief interventions (20 minutes). 7. Evaluation (15 minutes). Preparation 1. What do we need to know on tobacco use and tobacco dependence? (10 minutes) Brainstorming In order effectively to help tobacco users quit, what do you need to know about tobacco use and tobacco dependence?
In order to assist patients in quitting more effectively, every health-care provider should have some basic knowledge of tobacco use and tobacco dependence – such as the impact of tobacco use, the benefits of quitting tobacco use, and why people smoke and do not quit. Presentation 2. The impact of tobacco use on tobacco users and others (10 minutes) Brainstorming What is the impact of tobacco use on tobacco users and others?
Tobacco use will have both health and non-health impacts on tobacco users and others.
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Participants’ workbook
2.1 Health impact Tobacco kills up to half of its users. As a leading cause of death and illness, tobacco kills more than 5 million people who directly use tobacco (both smoking and smokeless). Second-hand smoke also kills. Second-hand smoke causes more than 600 000 premature deaths per year. Smoking is bad for health because tobacco smoke contains more than 7000 chemicals, of which at least 250 are known to be harmful and at least 69 are known to cause cancer. Figure 2 shows some examples of the chemicals contained in tobacco smoke. Figure 3 illustrates that tobacco use and second-hand smoke damage every part of the body. Smokeless tobacco is also highly addictive and causes cancer of the head and neck, oesophagus and pancreas, as well as many oral diseases. There is evidence that some forms of smokeless tobacco may also increase the risk of heart disease and low-birth-weight babies. 2.2 Common misconceptions about health effects of tobacco held by tobacco users Many tobacco users, especially those in developing countries, do not completely understand the dangers of tobacco due to tobacco companies’ misleading data that distort the health impact of tobacco use. Below are some common misconceptions of tobacco use held by tobacco users. Low-tar cigarettes are safe to smoke. There is no safe cigarette; a low-tar cigarette is just as harmful as other cigarettes. Although low-tar cigarettes can be slightly less damaging to your lungs over a long period of time, people who smoke these have been shown to take deeper puffs, puff more frequently and smoke the cigarettes to a shorter butt length. Switching to low-tar cigarettes has few health benefits compared with the benefits of quitting. “Rollies” are safe to smoke. Roll-your-own (RYO) tobacco contains many of the same chemicals as manufactured cigarettes. Research suggests that RYO tobacco is at least as harmful, and possibly more harmful, than smoking factory-made cigarettes. Studies show that RYO smokers tend to make cigarettes that can yield high levels of tar and nicotine. They may also not use a filter. Both RYO-only and mixed smokers report inhaling more deeply than smokers of factory-made cigarettes. More research is required to determine the levels of chemicals inhaled by RYO smokers. Cutting down the number of cigarettes I smoke will reduce my health risks. There is no safe level of cigarette consumption. Some people try to make their smoking habit safer by smoking fewer cigarettes, but most find this hard to do and quickly return to their old pattern. Although reducing your cigarette consumption will slightly reduce your risk, quitting is the only way to long-term health benefits. Just three cigarettes a day can trigger potentially fatal heart disease, with women particularly at risk. Only old people get ill from smoking. Anyone who smokes tobacco increases their risk of ill-health. All age groups suffer short-term consequences of smoking that include decreased lung function, shortness of breath, cough and rapid tiring during exercise. Smoking also diminishes the ability to smell and taste, and causes premature ageing of the skin.
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Participants’ workbook
Smoking-related diseases often develop over a number of years before a diagnosis is made. The longer you smoke, the greater your risk of developing cancer, heart, lung and other preventable diseases. However, people in their 20s and 30s have died from strokes caused by smoking. Everyone who quits smoking puts on weight. When you stop smoking you are likely to find you have a larger appetite and be tempted to replace cigarettes with food. You can avoid weight gain after quitting by being aware of this and doing extra exercise and adopting healthy eating habits. 2.3 Economic impact of tobacco use Tobacco imposes enormous economic costs on individuals, the family and the country. Tobacco’s economic costs include: • direct costs: − tobacco-related death; − tobacco-related productivity losses; • indirect costs: − health-care expenditures for smokers and people exposed to second-hand smoke; − employee absenteeism and reduced labour productivity; − fire damage due to careless smokers; − increased cleaning costs; − widespread environmental harm from large-scale deforestation, pesticide and fertilizer contamination, and discarded litter. Figure 2. Chemicals in cigarette smoke
2.3.1 Costs to the society The estimated annual cost of tobacco use to societies globally is US$ 500 billion, exceeding the total annual expenditure on health in all low-and middle-income countries.
Source: WHO (2009). WHO report on the global tobacco epidemic, 2009: implementing smoke-free environments.
Every country suffers huge economic losses due to tobacco use (see some examples in Table 3). Tobacco’s total economic costs reduce national wealth in terms of gross domestic product (GDP) by as much as 3.6%.
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Participants’ workbook
Figure 3. Diseases caused by smoking and second-hand smoke
Source: U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010.
Table 3. Cost* attributable to tobacco use (US$) (2007 or latest available data) USA Japan Germany Canada France China Egypt 167.00 billion 62.39 billionover one year 23.75 billion 17.00 billion 15.30 billion 5.00 billion 1.25 billion
* Direct health-care costs plus indirect costs, including productivity losses, absenteeism and other socioeconomic costs.
2.3.2 Costs to families and individuals Another significant cost related to tobacco use is the suffering of families and individuals because of diminished quality of life, death and financial burden. “Smoking makes the poor poorer; it takes away not just their health but wealth.” (Dr. Bill O’Neill, Secretary of the British Medical Association Scotland, 2004).
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Participants’ workbook
Tobacco products are expensive. For example, the price of 20 Marlboro cigarettes could buy: − a dozen eggs in Panama; − one kilogram of fish in France; − four pairs of cotton socks in China; − six kilograms of rice in Bangladesh. Tobacco use is costly with 5−15% of tobacco users’ disposable income spent on tobacco. Poor people often have to cut their expenditure on food and education. 3. Benefits of quitting tobacco use (10 minutes) 3.1 Health benefits Quitting tobacco use saves lives and money. Fact sheet 1 summarizes the health benefits of smoking cessation.
Fact sheet 1: Health benefits of smoking cessation A. There are immediate and long term health benefits of quitting for all smokers. Time since quitting Within 20 minutes 12 hours 2-12 weeks 1-9 months 1 year 5 years 10 years 15 years Beneficial health changes that take place Your heart rate and blood pressure drop. The carbon monoxide level in your blood drops to normal. Your circulation improves and your lung function increases. Coughing and shortness of breath decrease. Your risk of coronary heart disease is about half that of a smoker. Your stroke risk is reduced to that of a non-smoker 5 to 15 years after quitting. Your risk of lung cancer falls to about half that of a smoker and your risk of cancer of the mouth, throat, esophagus, bladder, cervix, and pancreas decreases. The risk of coronary heart disease is that of a non-smoker’s
B. Benefits for all ages and people who have already developed smoking-related health problems. They can still benefit from quitting. Time of quitting smoking At about 30 At about 40 At about 50 At about 60 After the onset of lifethreatening disease Benefits in comparison with those who continued Gain almost 10 years of life expectancy Gain 9 years of life expectancy Gain 6 years of life expectancy Gain 3 years of life expectancy Rapid benefit, people who quit smoking after having a heart attack reduce their chances of having another heart attack by 50 per cent.
C. Quitting smoking decreases the excess risk of many diseases related to second-hand smoke in children, such as respiratory diseases (e.g., asthma) and ear infections. D. Quitting smoking reduces the chances of impotence, having difficulty getting pregnant, having premature births, babies with low birth weights, and miscarriage.
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Participants’ workbook
3.2 Economic benefits Quitting has clear economic benefits. The quit & save exercise can help you understand how much money you can save if you quit. Quit & Save How much money can you save if you quit? Total money spent on tobacco per day Amount of money spent per month Amount of money spent per year Amount of money spent in 10 years
What you can buy with the money saved?
4. Overview of local, national and worldwide patterns of tobacco use (10 minutes) 4.1 Worldwide patterns of tobacco use Cigarette smoking Figure 4. Four stages of the tobacco epidemic
70 60 50 40
STAGE 1
STAGE 2
STAGE 3
STAGE 4
40 Percentage of deaths caused by smoking
Percentage of smokers among adults
% male smokers
% female smokers
30
20 30 20 10 0 0 10 20 • Sub-Sahara Africa 30 40 • China • Japan • Southeast Asia • Latin America • North Africa 50 60 70 • Eastern Europe • Southern Europe • Latin America 80 % female deaths 0 90 100 • Western Europe • UK • USA • Australia • Canada
% male deaths 10
Source: Lopez AD, Collishaw NE, and Piha T. (1994). A descriptive model of the cigarette epidemic in developed countries. Tobacco Control 3: 242-247.
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Participants’ workbook
With respect to cigarette smoking, WHO has developed a model of the four stages of the evolving epidemic that links the various stages of the tobacco epidemic into a continuum (Figure 4) to allow virtually every country to find itself in relation to the larger pandemic. It also illustrates the connection between the indices used to monitor the epidemic in a particular country and the natural evolution involving tobacco marketing, dependence on manufactured cigarettes, and ultimately the disease burden caused by these products within and across countries. Unlike many other dangerous substances, for which the health impacts may be immediate, tobaccorelated disease usually does not begin for years or decades after tobacco use starts. Because developing countries are still in the early stages of the tobacco epidemic, they have yet to experience the full impact of tobacco-related disease and death already evident in wealthier countries where tobacco use has been common for much of the past century. There are more than one billion smokers in the world. Nearly 80% of them live in low- and middleincome countries. Unless urgent action is taken, the number of smokers worldwide will continue to increase. Consumption of tobacco products Consumption of tobacco products is increasing globally, though it is decreasing in some high-income and upper-middle-income countries. Tobacco use is growing fastest in low-income countries, due to steady population growth coupled with tobacco industry targeting. Figure 5 shows that tobacco will kill over 175 million people worldwide between now and the year 2030. Figure 5. Cumulative tobacco-related deaths, 2005 – 2030
200 World 180 Cumulative tobacco-related deaths (millions) Developing countries 160 Developed countries 140 120 100 80 60 40 20 0 2005 2010 2015 2020 2025 2030 Source: Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030 PLoS Medecine, 2006, 3(11):e442.
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Participants’ workbook
Tobacco use among adolescents and women The vast majority of smokers begin using tobacco products well before the age of 18 years. Today, surveillance of tobacco use among youth in several countries has revealed that the problem is of equal concern in developed and developing countries. Statistics reveal that the use of any form of tobacco by 13–15-year-old students is greater than 10% (Table 4). In addition, almost one in four students (13–15 years of age) who ever smoked cigarettes smoked their first cigarette before the age of 10 years. Further, recent studies have revealed that there is little difference between the sexes in cigarette smoking or in use of other tobacco products. Table 4. GYTS measures of tobacco use, by sex and WHO region, 1999 – 2005 Current any tobacco use* Total Total African Region Region of the Americas Boy Girl Current cigarette smoking** Total Boy 10.5 (8.1-12.9) 13.0 (9.4-16.6) Girl 6.7 (5.0-8.4) 5.8 (3.5-8.1) Current other tobacco use*** Total Boy Girl 7.8 (6.0-9.6) 9.9 (7.3-12.5) 7.8 (6.2-9.4)
17.3 20.1 14.3 8.9 (14.8-19.8) (16.7-23.5) (11.5-17.1) (7.2-10.6) 16.8 19.7 13.9 9.2 (14.1-19.5) (15.8-23.6) (10.8-17.0) (7.0-11.4)
11.2 13.8 (9.7-12.7) (11.7-15.9) 10.5 (8.3-12.7) 10.9 (8.0-13.8)
22.2 24.0 20.4 17.5 17.4 17.5 11.3 14.8 (19.8-24.6) (21.0-27.0) (17.6-23.2) (15.2-19.8) (14.7-20.1) (14.9-20.1) (9.8-12.8) (12.6-17.0) 5.0 (3.3-6.7) 6.7 (4.4-9.0) 3.2 (1.1-5.3)
Eastern Mediter15.3 18.8 11.3 ranean Region (12.7-17.9) (15.2-22.4) (8.0-14.6) European Region South-East Asia Region
12.9 15.6 9.9 (10.6-15.2) (12.4-18.8) (7.3-12.5) 10.0 (6.7-13.3) 6.0 (4.0-8.0)
19.8 22.3 17.0 17.9 19.9 15.7 8.1 (16.6-23.0) (18.0-26.7) (13.8-20.2) (15.2-20.6) (16.1-23.7) (13.6-18.8) (5.8-10.4) 12.9 18.4 (10.2-15.6) (14.3-22.5) 7.1 (4.7-9.5) 7.8 (5.8-9.8) 4.3 (3.1-5.5) 6.5 (4.9-8.1) 5.8 (4.4-7.5) 9.9 (7.1-12.7) 1.9 (1.0-2.8) 3.3 (2.1-4.5)
13.3 16.4 8.4 (12.3-14.3) (15.0-17.8) (6.8-10.0) 6.4 (5.2-7.6) 7.7 (6.1-9.3) 5.4 (3.9-6.9)
Western Pacific 11.4 15.0 Region (9.5-13.3) (12.2-17.8)
Data are prevalence (95% CI). * smoked cigarettes or used other tobacco products during the past 30 days. ** smoked cigarettes on 1 or more days in the past 30 days. ***used other tobacco products (e.g. chewing tobacco, snuff, dip, cigars, cigarillos, little cigars, pipe, bidis, waterpipe, or betel nut with tobacco) during the past 30 days. Source: Warren CW et al. Global Tobacco Surveillance System (GTSS) collaborative group. Patterns of global tobacco use in young people and implications for future chronic disease burden in adults. Lancet, 2006, 749–753.
The rise in tobacco use among younger females in high-population countries is one of the most ominous potential developments of the epidemic’s growth. In many countries, women have traditionally not used tobacco: women smoke at about one fourth the rate of men. Because most women currently do not use tobacco, the tobacco industry aggressively markets to them to tap this potential new market.
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Smokeless tobacco There are four major forms of oral smokeless tobacco. • Chewing tobacco is shredded like short cut grass, generally mildly acidic and intended to be chewed throughout the day as desired. • Snuff is chopped into particles like large coffee grounds, moistened and used by holding between gum and cheek. • Swedish snus is a variant on snuff that is processed differently so that some variants must be kept refrigerated: it is typically more moist. • Gutkha and other oral smokeless tobacco products are used in India and South-east Asia. In some regions of the world, the use of oral smokeless tobacco remains the dominant form of tobacco use. For example, in India, where oral smokeless tobacco is the dominant form of tobacco use, the incidence of oral cancer is high, accounting for one third of the world burden. Smokeless tobacco is commonly used in other South-East Asian countries as well (Table 5). Its consumption is prominent in Scandinavia and the United States of America. Table 5. Smokeless tobacco use in three South-East Asian countries Countries India Bangladesh Thailand Current smokeless tobacco users (%) 25.9 27.2 3.9 Daily smokeless tobacco users (%) 21.4 23.7 3.4
Source: Global Adult Tobacco Survey country reports and fact sheets.
4.2 Local and national patterns of tobacco use For the profile of tobacco use in each specific country, please refer to the WHO tobacco control country profiles which were generated from data collected for the WHO report on the global tobacco epidemic, 2011: warning about the dangers of tobacco. The country profiles provide information about tobacco prevalence in 193 WHO Member States. In terms of local patterns of tobacco use, please contact your local health authority for detailed data. 5. Why people smoke and do not quit (25 minutes) Brainstorming Why do people smoke and why don’t they quit?
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People smoke for many reasons. If you ask smokers, they may tell you the following reasons: − addiction; − everyone does it; − social activity; − after a meal; − stress relief; − when having coffee or tea; − emotional support; − sharing of cigarettes; − boredom/filling in time; − bonding/acceptance. The list of reasons why people smoke can help us realize that smoking/tobacco addiction is made up of three elements: − physical /physiological addiction to nicotine; − emotional/psychological connection; − habitual and social connection. 5.1 Physical/physiological addiction Nicotine Nicotine is as addictive as many illegal drugs. Nicotine has been shown to have effects on brain dopamine systems similar to those of drugs such as heroin and cocaine. Nicotine increases the number of nicotinic receptors in the brain. Inhalation (smoking) is the quickest way for nicotine to reach brain (within 7−10 seconds). As a smoker, your brain and body get used to functioning with a certain level of nicotine. Your nicotine level will drop dramatically one or two hours after your last cigarette (the half-life of nicotine is 120 minutes), and then you will crave nicotine (cigarettes). If you stop smoking suddenly, the absence of nicotine in your brain (the nicotinic receptors in your brain are empty) will make you feel uncomfortable and cause withdrawal symptoms. Nicotine withdrawal symptoms Nicotine withdrawal symptoms refer to a group of symptoms (the physical and mental changes) that may occur from suddenly stopping the use of tobacco. Withdrawal is the adjustment of the body to living without nicotine, positively referred to as recovery symptoms. They are normally temporary (2−4 weeks) and are a product of the physical or psychological adaptation. Most smokers know about withdrawal symptoms through hearsay or from direct experience. They can be a major barrier against staying quit, or even attempting to quit in the first place. Some common nicotine withdrawal symptoms are: − headaches; − restlessness; − coughing; − decreased heart rate; − cravings; − difficulty concentrating; − increased appetite or weight gain; − influenza-like symptoms; − mood changes (sadness, irritability, − insomnia. frustration, or anger); 5.2 Emotional/psychological connection Smokers link feelings with cigarettes via the process of withdrawal and “operant conditioning”. Here are some of the emotional connections that may be associated with smoking: when smokers feel stressed, happy, sad or angry, they will get craving for a cigarette. In fact, using cigarettes to calm your nerves or cope with stress is misguided. It does not help solve the source of your problems. 33
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Other psychological factors relevant to smoking are cognitions (i.e. thoughts and beliefs). Smokers who do not want to quit may have positive thoughts and beliefs on smoking, such as: − “It helps me relax.” − “It’s not really that harmful!” − “It’s cool to smoke!” − “It keeps my weight down.” 5.3 Habitual and social connection Smoking is a tenacious habit precisely because it is so intimately tied to the everyday acts in smokers’ lives. Smokers link behaviour with cigarettes via the process of “operant conditioning”. It is not easy to let go of something that’s been such an integral part of a smoker’s life for so long. Smoking may be associated with the following habits or behaviour: having coffee or tea, the end of meal, making a phone call, watching television, driving. Smoking is also prone to social influences. Children and adolescents are more likely to start smoking if their parents or people they respect and admire smoke. Smoking with friends is a way to socialize with them. 5.4 Interactions between the three elements of tobacco addiction The physical, psychological and social influences are not independent of each other. All three types of factors influencing smoking need to be explored and referred to when you provide support for tobacco users to quit. Practice 6. Applying the knowledge of tobacco addiction to deliver brief interventions (20 minutes) Pair up with the person sitting next to you to list two ways in which you should use the knowledge of tobacco addiction when delivering brief interventions. Be prepared to share your list in the whole group.
7. Evaluation (15 minutes) Please volunteer to share your two ways of using the knowledge of tobacco addiction when delivering brief tobacco interventions. Please help provide your comments on the other participants’ responses.
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Module 9: Promoting brief tobacco interventions in the community
Summary Tobacco is the single most preventable cause of death globally. Tobacco is deadly in any form or disguise. Tobacco use and second-hand smoke damage every part of the body. Tobacco also imposes enormous economic costs on individuals, families and the country. Quitting tobacco saves lives and money. People smoke and do not quit for many reasons, which can be classified into three factors: physical, psychological, habitual and social influences. Nevertheless, with determination and a smart strategy, it is possible to quit tobacco use. Health-care providers should use the knowledge of tobacco addictions to deliver brief tobacco interventions.
Module 3: Overview of brief tobacco interventions Objectives Upon completion of this module participants will be able to: − describe the purpose and population impact of a brief tobacco intervention; − describe at least three brief tobacco intervention models; − role-play the 5A’s brief tobacco intervention model. Agenda 1. Experiences of talking to patients about tobacco use (15 minutes). 2. The purpose, impact and delivery models of brief tobacco interventions (30 minutes). 3. Pre-training role play of a brief tobacco intervention (30 minutes). 4. Evaluation (15 minutes). Preparation 1. Experiences of talking to patients about tobacco use (15 minutes) Question: What are your experiences of talking to patients about smoking?
As a health professional, you may feel frustrated as many tobacco users are resistant to change and you do not know how to reduce their resistance and support them to quit tobacco use. In this module, you will find several effective brief tobacco intervention models to help you talk to patients about quitting tobacco and deliver advice.
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Presentation 2. The purpose, impact and delivery models of brief tobacco interventions (30 minutes) 2.1 Purpose Generally, brief tobacco interventions are not intended to treat people with high tobacco dependence (heavy tobacco users). The primary purpose of a brief tobacco intervention is to help the patient understand the risks of tobacco use and the benefits of quitting, and to motivate them to make a quit attempt. Brief tobacco interventions can also be used to encourage those heavy tobacco users to seek or accept a referral to more intensive treatments within their community. It is estimated that approximately 40% of tobacco users make some form of attempt to quit in response to advice from a doctor. 2.2 The population impact The success of a service or a public health programme is measured by its reach (number of people who receive the service/intervention), effectiveness (percentage of people who change their behaviour as a result of the service/intervention) and cost per person to deliver. Brief tobacco interventions take a few minutes – even small effect sizes – they can have significant population impact at relatively low cost if interventions are delivered routinely and widely across a health-care system. • Reach: in developed countries, 85% of the population visit a primary care clinician at least once per year. • Effectiveness: the quit rate is 2% (95% confidence interval 1−3%). • Cost: this is very low (a few minutes opportunistic intervention as part of primary care providers’ routine practice). 2.3 Effective brief tobacco intervention models There are several structured brief tobacco intervention models that can guide you through the right process to talk to patients about tobacco use and deliver advice. Below are some examples of brief tobacco intervention models.
2.3.1 The 5A’s: Ask, Advise, Assess, Assist, Arrange (for patients who are ready to quit) Ask – Systematically identify all tobacco users at every visit. Advise – Advise all tobacco users that they need to quit. Assess – Determine readiness to make a quit attempt. Assist – Assist the patient with a quit plan or provide information on specialist support. Arrange – Schedule follow-up contacts or a referral to specialist support.
Ask: We need to ask ALL of our patients if they use tobacco and make it part of our routine. Only then can we start to make a real difference to the tobacco use rates around us. Tobacco use should be asked about in a friendly way – it is not an accusation! Advise: Your advice should be clear and positive. It should also be tailored to the particular patient’s characteristics and circumstances.
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Assess: This will be determined by whether the patient wants to be a non-tobacco user, and whether they think they have any chance of quitting successfully. Assist: If the patient is ready to quit then he or she will need some help from us. We need to assist tobacco users in developing a quit plan or to tell them about specialist support if it is available. The support needs to be described positively but realistically. Arrange: If the patient is willing to make a quit attempt we should arrange follow-up around one week after the quit attempt, or arrange referrals to the specialist support.
2.3.2 The 5R's: Relevance, Risks, Rewards, Roadblocks, Repetition (to increase motivation of patients who are not ready to quit) Tobacco users may be unwilling to quit due to misinformation, concern about the effects of quitting, or demoralization because of previous unsuccessful quit attempts. Therefore, after asking about tobacco use, advising the tobacco user to quit, and assessing the willingness to make a quit attempt, it is important to provide the 5R’s motivational intervention. Relevance – How is quitting most personally relevant to you? Risks – What do you know about the risks of smoking in that regard? Rewards – What would be the benefits of quitting in that regard? Roadblocks – What would be difficult about quitting for you? Repetition – Repeat assessment of readiness to quit; if still not ready to quit, repeat intervention at a later date.
2.3.3 AAR: Ask, Advise, Refer This is an alternative protocol that takes less training and can easily be implemented. The primary care provider asks or identifies tobacco-using patients, advises them to quit (thus doubling the chances that they will try), and refers them to a quitline or other existing resource (see Module 9 for more information). 2.3.4 AAA: Ask, Advise, Act Ask about tobacco use. A clinic-wide system will need to be put in place to ensure that tobacco-use status is obtained and recorded for every patient at every office visit. Advise tobacco users to quit. In a clear, strong, and personalized manner, urge every tobacco user to quit. Act on patient’s response, assist the tobacco user in developing a quit plan and give advice on successful quitting. 2.3.5 ABC: Ask, Brief advice, Cessation support A – Ask about tobacco-using status. B – Give Brief advice to all tobacco users to stop using tobacco. C – Provide evidence-based Cessation support for those who express a desire to stop.
You can take an online course about tobacco cessation and the ABC model through the link: https://smokingcessationabc.org.nz.
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Summary The 5As (Ask, Advise, Assess, Assist, Arrange) summarize all the activities that a primary care provider can do to help a tobacco user within 3−5 minutes in a primary care setting. It does not mean you have to do all of these five activities/steps at every visit. In fact, you can start and stop at any step, as indicated in the following diagram, based on tobacco users’ different stages of quitting. The key is that you should routinely take a few minutes to support tobacco users to quit by using the 5A’s model as a guide.
Ask
Arrange
Quit plan and follow-up plan
Advise
Assist
Asses
Practice 3. Pre-training role play of a brief tobacco intervention (30 minutes) Practice is important for you to improve your confidence and skills in delivering brief tobacco interventions. There will be several opportunities for you to practise 5A’s and 5R’s brief tobacco interventions during the course. Volunteer to role-play a brief intervention in front of the group: • Volunteer 1 will be a doctor who attempts to address the patient’s smoking. • Volunteer 2 will be a fortyish male satisfied smoker who is not especially keen to stop. 4. Evaluation (15 minutes) Each participant provides feedback/ questions on the volunteers’ role play of the brief tobacco interventions. Summary There are several structured delivery models available to guide primary care providers to deliver brief tobacco interventions in primary care settings. The main purpose of brief tobacco interventions is to motivate tobacco users to make a quit attempt and to encourage heavy tobacco users to seek or accept a referral for a more intensive treatment. Brief tobacco interventions take a few minutes – but if done routinely – they can significantly increase the numbers of people quitting and save lives!
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Module 4: Asking, advising and assessing readiness to quit Objectives Upon completion of this module participants will be able to: • ask and advise patients about their tobacco use in an appropriate way; • use two ways to assess patients’ readiness to quit. Agenda 1. How giving advice on clinical issues differs from giving advice on behaviour change (15 minutes). 2. How to ask about tobacco use (10 minutes). 3. How to tailor advice for a particular patient (20 minutes). 4. How to assess readiness to quit (20 minutes). 5. Role playing exercise for tailoring advice (20 minutes). 6. Evaluation (20 minutes). Preparation 1. How giving advice on clinical issues differs from giving advice on behaviour change (15 minutes) Question 1: How does giving advice on clinical issues (e.g. “you have asthma”) differ from giving advice on behaviour change (e.g. “you need to quit smoking”)?
Primary care providers may feel more knowledgeable and confident to give advice on clinical issues because they know more than patients, and they have clear instructions or advice for patients. However, giving advice on behaviour change is more than providing information and recommending solutions to patients, but involves helping patients discover their own solutions to their problems and to accept patients’ choices. It requires primary care providers to establish a good relationship with patients, and to show empathy to them. The advice on behaviour change should be tailored to patients’ particular circumstances. Question 2: How can we tell if someone is ready to quit?
If someone is ready to quit, he or she should believe quitting is an important thing to do, and he or she can quit successfully.
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Presentation 2. How to ask about tobacco use (10 minutes) Primary care providers should ask about tobacco use at EVERY encounter, and document tobacco use status in the medical record. Please ask simple questions like: • Do you use tobacco? • Does anyone else smoke around you? Asking and recording tobacco use status is the first important step towards helping patients stop tobacco use. Health facilities should make a system change to ensure that, for every patient at every visit, tobacco use status is asked and documented. One strategy could be to include tobacco use status in medical records as a “vital sign”.
VITAL SIGNS Blood pressure: Pulse: Temperature: Respiratory rate: Tobacco use (circle one): Current Former Never Weight:
3. How to tailor advice for a particular patient (20 minutes) Primary care providers should advise patients to quit in a clear, strong and personalized manner. • Clear – “It is important that you quit smoking (or using chewing tobacco) now, and I can help you.” “Cutting down while you are ill is not enough.” “Occasional or light smoking is still dangerous.” • Strong – “As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. The clinic staff and I will help you.” • Personalized – Tie tobacco use to: − Demographics: For example, women may be more likely to be interested in the effects of smoking on fertility than men. − Health concerns: Asthma sufferers may need to hear about the effect of smoking on respiratory function, while those with gum disease may be interested in the effects of smoking on oral health. “Continuing to smoke makes your asthma worse, and quitting may dramatically improve your health.” − Social factors: People with young children may be motivated by information on the effects of second-hand smoke, while a person struggling with money may want to consider the financial costs of smoking. “Quitting smoking may reduce the number of ear infections your child has.” In some cases, how to tailor advice for a particular patient may not always be obvious. A useful strategy may be to ask the patient: − “What do you not like about being a smoker?” − The patient’s answer to this question can be built upon by you with more detailed information on the issue raised.
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− Example: Doctor: “What do you not like about being a smoker?” Patient: “Well, I don’t like how much I spend on tobacco.” Doctor: “Yes, it does build up. Let’s work out how much you spend each month. Then we can think about what you could buy instead!” You will have an opporutnity to practise how to provide tailored adivce on smoking later on. 4. How to assess readiness to quit (20 minutes) 4.1 When is someone ready to quit? As shown in Figure 6, readiness to quit has two key dimensions of importance and self-efficacy (confidence in one’s own ability to succeed in changing a target behaivour). To be ready to quit we need to see quitting as important and feel confident that we can quit successfully. • A tobacco user is more likely to show a desire to be a non-user and say “I want to be a non-tobacco user” if he or she believes “quitting is important”. • A tobacco user is more likely to say “I have a chance to quit successfully” if he or she has high level of confidence in their ability to quit. Figure 6. The components of readiness to quit
Readiness to quit
Importance
Self-efficacy
4.2 Assessing readiness to quit Method 1: Ask two questions in relation to “importance” and “self-efficacy”: “Would you like to be a non-tobacco user?” “Do you think you have a chance of quitting successfully?” Any answer in the shaded area indicates that the tobacco user is NOT ready to quit. In these cases we should deliver the 5R’s intervention (see Module 5 for more information).
Would you like to be a non-tobacco user? Do you think you have a chance of quitting successfully?
Yes Yes
Unsure Unsure
No No
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Method 2: Ask just one question: “Would you like to quit tobacco within the next 30 days?” If the answer is “no”, this indicates that the tobacco user is NOT ready to quit and we should deliver the 5R’s intervention. Summary Method 2 is a simpler way to assess a tobacco user’s readiness to quit, but using the two-question method (Method 1) can help primary care providers get more information from patients about their perceived importance and self-efficacy for change in order to conduct appropriate motivational interventions if patients are not ready to quit. Practice 5. Role-playing exercise for tailoring advice (20 minutes) Please volunteer to play the role of a primary care provider. You will need to: − ask about the patient’s smoking; − give some tailored advice using the following instructions. The facilitator will adopt the role of three fictional smokers (Hamid, Lisa and Mustafa). Each smoker will differ as to the demographic background, health status, family and social circumstances, and beliefs about smoking. Before each role play the fictional smoker (played by the facilitator) will introduce himself or herself. Smokers 1. Hamid: “I am a 57-year-old man with 10 grandchildren. I have a heart condition and breathing problems.” 2. Lisa: “I am a 25-year-old woman and I have just married. We hope to have a large family but we do struggle financially.” 3. Mustafa. “I am a man aged 35.” Primary care provider Advice should refer to health, longer life and passive smoking of grandchildren. Advice should refer to fertility and the financial impact of smoking. Mustafa does not give much information. The volunteer will need to recognize this and should ask Mustafa what he doesn’t like about being a smoker. Once Mustafa answers, the volunteer should add extra information on the issue raised.
6. Evaluation (20 minutes) Each participant provides feedback/questions on role plays by volunteers and facilitator. Summary Asking and recording tobacco use status is the first important step towards helping patients stop tobacco use. Health facilities must implement a system change to ensure that, for every patient at every visit, tobacco use status is asked and documented. Advice on quitting should be clear, strong and personalized. You may need to ask the patient for more information when it is not obvious how to tailor advice for a particular patient. Tobacco users’ readiness to quit depends on their beliefs about the importance of quitting and level of confidence in their abillity to quit successfully. We can use two methods to assess a tobacco user’s readiness to quit.
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Module 5: Dealing with low motivation Objectives Upon completion of this module participants will be able to: − describe the 5R’s brief tobacco intervention model; − respond appropriately to exhibited stop-smoking resistance, employing the 5R’s model; − respond appropriately in cases of low motivation to quit, using motivational tools. Agenda 1. Definition of motivation (15 minutes). 2. Overview of the 5R’s model (15 minutes). 3. Motivational tools (15 minutes). 4. Role-playing of 5R’s interventions (30 minutes). 5. Evaluation (15 minutes). Preparation 1. Definition of motivation (15 minutes) Question 1: What is motivation?
In general, motivation is the driving force by which humans achieve their goals. The word “motivation” here refers to “intrinsic motivation”: the key predictor of behaviour change. According to behavioural scientists, “intrinsic motivation” is an internal state that activates, directs and maintains behaviour towards goals. In this workbook, we define it as the state of readiness to change. Question 2: What are your experiences of dealing with tobacco users who are not willing to quit?
Many health professionals find that it seems impossible to create positive dialogue with unmotivated patients about their behaviours. They often make patients angry and receive all kinds of excuses as to why these changes are not appropriate when they try to give advice to unmotivated patients. In this module, you will learn and practise using the 5R’s model and some other tools to deal with tobacco users who have low motivations to quit.
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Presentation 2. Overview of the 5R’s model (15 minutes) The 5R’s model is a brief motivational intervention that is based on principles of motivational interviewing (MI), a directive, patient-centred counselling approach. Motivational interviewing was developed by William Miller and Stephen Rollnick in the 1980s on the basis of their experiences of working with people who had problems with drinking alcohol. MI is a relatively new cognitive-behavioural technique that aims to increase the person’s intrinsic motivation for change based on the person’s own personal goals and values. Compared to traditional practitioner-centred, expert-directed counselling methods, MI is a different way of being with people: • It is an interviewing conversation and elicits careful questioning and listening on both sides. Information is shared reciprocally and is nonjudgmental. • It takes place in a supportive, patient-centred atmosphere, where patients feel comfortable enough to explore their own reality and conflicts. • It keeps the tone motivational rather than argumentative and meets a patient’s resistance with a different approach. Instead of confrontation or opposition, the practitioner keeps the conversation open, positive and on course. • It centres the locus of control within the patient. Change is the choice of the patient rather than of the practitioner. Principles of MI are: (1) express empathy, (2) develop discrepancy, (3) roll with resistance, and (4) support self-efficacy. Express empathy Use open-ended questions, affirming, listening reflectively and summarizing in order to understand the patient’s perspectives without judging, criticizing or blaming. Examples: “How important do you think it is for you to quit smoking?” “What might happen if you quit?” “So you think smoking helps you maintain your weight.” “What I have heard so far is that smoking is something you enjoy. On the other hand, you are worried you might develop a serious disease.” Express your willingness to accept “where” a patient is (his/her place of readiness). For instance, “I hear you saying you are not ready to quit smoking right now. I’m here to help you when you are ready.” Develop discrepancy Use strategies to assist the patient in identifying discrepancy and move forward change. Highlight the discrepancy between the patient’s present behaviour and expressed priorities, values and goals. For instance, “It sounds like you are very devoted to your family. How do you think your smoking is affecting your children?” Roll with resistance Use strategies to re-assess readiness, and for reflective listening. Example: “You are worried about how you would manage withdrawal symptoms.” Emphasize personal choice and control. Example: “Would you like to hear about some strategies that can help you address that concern when you quit?”
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Support self-efficacy
Help the patient identify and build on past successes. Example: “So you were fairly successful the last time you tried to quit.” Offer options for achievable small steps towards change, such as: – read about quitting benefits and strategies; – change smoking patterns (e.g. no smoking in the home); – ask the patient to share his or her ideas about quitting strategies; – try quitting smoking for one or two days. Arrange for the patient to observe role models who quit smoking successfully. Encourage and convince the patient that success is a result of self: “I have tried 16 times to quit smoking.” “Wow, you’ve already shown your commitment to trying to stop smoking several times. That’s great! More importantly you’re willing to try again.” Teach the patient relaxation techniques to minimize stress and to elevate mood.
2.1 The components of the 5R’s model The 5R’s – relevance, risks, rewards, roadblocks and repetition – are the content areas that should be addressed in a motivational counselling intervention. Research suggests that the 5R’s enhance future attempts. Table 6 summarizes the components of the 5R’s model and provides an example of using the 5R’s model to help an unmotivated patient. Table 6. Components and example of the 5R’s Strategies for implementation Relevance Encourage the patient to indicate how quitting is personally relevant to him or her. Motivational information has the greatest impact if it is relevant to a patient’s disease status or risk, family or social situation (e.g. having children in the home), health concerns, age, sex, and other important patient characteristics (e.g. prior quitting experience, personal barriers to cessation). Risks Encourage the patient to identify potential negative consequences of tobacco use that are relevant to him or her. Examples of risks are: • Acute risks: shortness of breath, exacerbation of asthma, increased risk of respiratory infections, harm to pregnancy, impotence, and infertility. • Long-term risks: heart attacks and strokes, lung and other cancers (e.g. larynx, oral cavity, pharynx, esophagus, pancreas, stomach, kidney, bladder, cervix, and acute myelocytic leukemia), chronic obstructive pulmonary diseases (chronic bronchitis and emphysema), osteoporosis, long-term disability, and need for extended care. • Environmental risks: increased risk of lung cancer and heart disease in spouses; increased risk for low birth-weight, sudden infant death syndrome (SIDS), asthma, middle ear disease, and respiratory infections in children of smokers. Rewards Ask the patient to identify potential relevant benefits of stopping tobacco use. Examples of rewards could include: – improved health; – food will taste better; – improved sense of smell; – saving money; – feeling better about oneself; – home, car, clothing and breath will smell better; – setting a good example for children and decreasing the likelihood that they will smoke; – having healthier babies and children; – feeling better physically; – performing better in physical activities; – improved appearance, including reduced wrinkling/ageing of skin and whiter teeth. Example HCP: “How is quitting most personally relevant to you?” P: “I suppose smoking is bad for my health”
HCP: “What do you know about the risks of smoking to your health? What particularly worries you?” P: “I know it causes cancer. That must be awful.” HCP: “That’s right – the risk of cancer is many times higher among smokers.”
HCP: “Do you know how stopping smoking would affect your risk of cancer?” P: “I guess it would be lower if I quit.” HCP: “Yes, and it doesn’t take long for the risk to decrease. But it’s important to quit as soon as possible.”
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Strategies for implementation Roadblocks Ask the patient to identify barriers or impediments to quitting and provide treatment (problem-solving counselling, medication) that could address barriers. Typical barriers might include: – withdrawal symptoms; – fear of failure; – weight gain; – lack of support; – depression; – enjoyment of tobacco; – being around other tobacco users; – limited knowledge of effective treatment options. Repetition Repeat assessment of readiness to quit. If still not ready to quit repeat intervention at a later date.
Example HCP: “So what would be difficult about quitting for you?” P: “Cravings – they would be awful!” HCP: “We can help with that. We can give you nicotine replacement therapy (NRT) that can reduce the cravings.” P: “Does that really work?” HCP: “You still need will-power, but study shows that NRT can double your chances of quitting successfully.”
HCP: “So, now we’ve had a chat, let’s see if you feel differently. The motivational intervention should be repeated every time an unmotivated patient Can you answer these questions again…?” visits the clinic setting. (Go back to the Assess stage of the 5A’s. If ready to quit then proceed with the 5A’s. If not ready to quit, end intervention positively.)
HCP: health-care provider; P: patient
2.2 When do we deliver the 5R’s? 5R interventions will be delivered to those who are not ready to quit tobacco use after the “Assess” stage of the 5A’s.
Ask Advise Not ready to quit Asses Assist Arrange Ready to quit End positively
Five R’s Not ready to quit
2.3 Tips for implementing the 5R’s model • Let the patient do the talking. Don’t give lectures! • If the patient does not want to be a non-tobacco user – focus more time on “Risks” and “Rewards”. • If the patient does want to be a non-tobacco user but does not think he or she can quit successfully, focus more time on “Roadblocks”. • Even if patients remain not ready to quit, end positively with an invitation to them to come back to you if they change their minds.
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3. Motivational tools (15 minutes) In addition to talking to the patient, we can also use some tools to motivate tobacco users to quit. Here are some examples: • cost calculators (cost of smoking calculator, personal savings calculator); • photographs of tobacco-related diseases; • visual motivational tools such as: − carbon monoxide monitor, − pulmonary function testing (spirometry), − “lung age” indicator (graphically show the age of the average healthy person who has an FEV1 equal to that of the patient); • risk charts (facilitate physician-patient discussion about disease risk, e.g. WHO/ISH risk prediction charts). Each motivational tool has its advantages and disadvantages. The tool that primary care providers will use depends on how easy it is to understand the tool and whether the tool would be available to them. Practice 4. Role playing of 5R’s interventions (30 minutes) Please volunteer to play the role of two practitioners to assess two fictional smokers’ readiness to quit. The facilitator will adopt the role of the two fictional smokers. Each smoker will differ in his or her response when assessed for readiness to quit: A. Hamid: “My smoking isn’t really a concern to me.” In role play, Hamid should express concern about heart disease. B. Lisa: “I want to be a non-smoker but I could never quit – I’m very addicted.” In role play, Lisa should express concern about her stress levels while quitting. In role play, the two volunteers should: • complete the “Assess” questions appropriately in each case to indicate non-readiness to quit; • deliver the 5R’s interventions in an appropriate way. In the case of Hamid, the 5R’s should be delivered, focusing on Risks and Rewards. In the case of Lisa, the 5R’s should be delivered with the focus on Roadblocks. 5. Evaluation (15 minutes) Everyone gives feedback and comments on the role plays by the facilitator and two volunteers. The facilitator summarizes the practice and links it to the relevant learning objectives. Summary Several approaches can be used to help those who are not willing to quit tobacco use in primary care settings. The 5R’s model can help primary care providers apply the spirits, principles and skills of motivational interviewing for enhancing intrinsic motivation to change behaviour in brief contacts. Primary care providers can also consider using available motivational tools to motivate tobacco users to quit.
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Module 6: Assisting and arranging for follow-up Objectives Upon completion of this module participants will be able to: − assist patients to stop tobacco use by helping them with a quit plan and providing intra-treatment social support and supplementary materials; − arrange follow-up contacts; − arrange a referral to specialist services if available; − deliver a full, brief tobacco intervention according to the 5A’s and 5R’s models. Agenda 1. What kind of assistance a tobacco user will need to make a quit attempt (15 minutes). 2. How to assist patients in making a quit attempt (20minutes) 3. How to arrange follow up contacts for the patient (15 minutes). 4. The full brief tobacco intervention demonstration (25 minutes). 5. Role-playing of the full brief tobacco intervention (30 minutes). 6. Evaluation (15 minutes). Preparation 1. What kind of assistance a tobacco user will need to make a quit attempt (15 minutes) Brainstorming If you were a tobacco user, what kind of assistance would you need from the doctor to make a quit attempt?
A tobacco user may need the following assistance from the doctor to make a quit attempt: developing a quit plan, dealing with withdrawal symptoms, social support, and pharmacotherapy recommendations. Presentation 2. How to assist patients in making a quit attempt (20minutes) For the patient who is willing to quit, the following actions can be taken to aid the patient in quitting: − help develop a quit plan; − provide practical counselling; − provide intra-treatment social support; − help patient obtain extra-treatment social support; − recommend pharmacotherapy if appropriate; − provide supplementary materials. 2.1 Help develop a quit plan Strategies for this action can be summarized by the acronym STAR. Set a quit date, ideally within two weeks. Tell friends, family and coworkers of the plan to quit, and ask for support. Anticipate challenges, particularly during the critical first few weeks, including nicotine withdrawal. Remove cigarettes from home, car and workplace and avoid smoking in these places. Make your home smoke-free.
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2.2 Provide practical counselling to deal with challenges/difficulties while quitting The US Clinical Practice Guideline: Treating tobacco use and dependence: 2008 update summarizes core components of practical counselling (Table 7). Table 7. Common elements of practical counselling Practical counselling (problem solving/skills training) treatment component Recognize danger situations – identify events, internal states or activities that increase the risk of smoking or relapse. Examples – – – – – negative affect and stress; being around other tobacco users; drinking alcohol; experiencing urges; smoking cues and availability of cigarettes.
Develop coping skills – identify and practise coping or problemsolving skills. Typically, these skills are intended to cope with danger situations.
– learning to anticipate and avoid temptation and trigger situations; – earning cognitive strategies that will reduce negative moods; – accomplishing lifestyle changes that reduce stress, improve quality of life, and reduce exposure to smoking cues; – learning cognitive and behavioural activities to cope with smoking urges (e.g. distracting attention, changing routines). – any smoking (even a single puff) increases the likelihood of a full relapse; – withdrawal symptoms typically peak within 1–2 weeks after quitting but may persist for months (these symptoms include negative mood, urges to smoke, and difficulty concentrating); – the addictive nature of smoking.
Provide basic information about smoking and successful quitting.
Exercise - Answer questions asked by patients who are willing to quit: • What if I still have cravings? • What if I smoke after quitting? Primary care providers can answer the first question based on the following key points: • Cravings/urges occur even when smoking. Typically they are brief, lasting only 1−2 minutes. • There are many ways to deal with them. One good strategy is named “4Ds”: − Delay (every time you get the urge to puff, try to delay it as long as you can); − Deep breathing (deep breathing and meditation can help you relax yourself from within until the urge fades away); − Drink water (water refreshes the body and flushes out toxins); − Do something else (take a shower). • As time goes on, urges will occur less often and will become less intense. Primary care providers can answer the second question as follows: • Relapse is common. Most people make multiple attempts before they are successful. • If you smoke after quitting: − don’t blame yourself (none of us is perfect); − use the relapse as a learning experience rather than as a sign of failure; − just try another quit attempt.
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2.3 Provide intra-treatment social support Table 8 describes core elements of intra-treatment supportive interventions that you can provide to tobacco users. Table 8. Common elements of intra-treatment supportive inventions Supportive treatment component Encourage the patient in the quit attempt Examples • Note that effective tobacco dependence treatments are now available. • Note that one-half of all people who have ever smoked have now quit. • Communicate belief in patient’s ability to quit. • Ask how the patient feels about quitting. • Directly express concern and willingness to help as often as needed. • Ask about the patient’s fears and ambivalence regarding quitting. Ask about: – reasons why the patient wants to quit; – concerns or worries about quitting; – success the patient has achieved; – difficulties encountered while quitting.
Communicate caring and concern
Encourage the patient to talk about the quitting process
3. How to arrange follow-up contacts for the patient (15 minutes) When: The majority of relapse occurs in the first two weeks after quitting. Therefore, follow-up contact should begin soon after the quit date. The first follow-up contact should be arranged during the first week. A second follow-up contact is recommended within one month after the quit date. How: Use practical methods such as telephone, personal visit and mail/e-mail to do the follow-up. Following up with patients is recommended to be done through teamwork if possible. What: Table 9 describes all actions that primary care providers need to take during follow-up contacts Table 9. Actions for patients during follow-up contacts For all patients • • • • Identify problems already encountered and anticipate challenges. Remind patients of available extra-treatment social support. Assess medication use and problems. Schedule the next follow-up contact.
For patients who are abstinent For patients who have used tobacco again
• Congratulate them on their success. • Remind them to view relapse as a learning experience. • Review circumstances and elicit recommitment. • Link to more intensive treatment if available.
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4. The full brief tobacco intervention demonstration (25 minutes) Please volunteer to role-play a patient. The facilitator will deliver a full, brief intervention for the patient. The patient is Hamid (The participant may develop the character and dialogue as he or she wishes): He is a 57-year-old man with 10 grandchildren. He has a heart condition and breathing problems. At the moment, he is not particularly concerned about his smoking. Please provide comments and advice on how to proceed when the facilitator pauses at each stage of the 5A’s or 5R’s. Practice 5. Role-playing of the full brief tobacco intervention (30 minutes) Please assess your current level of confidence in delivering a full brief tobacco intervention on a scale of 0 to 10. If your confidence level is less than 7, that means you will need more practice. At this stage, it is natural to not feel confident in intervention delivery. You will become really confident about delivering the intervention once you have done it several times in “real-life”.
0
1
2
3
4
5
6
7
8
9
10
Not at all confident
Extremely confident
Please volunteer to role-play a brief intervention in front of the group. Four volunteers are needed: two for “primary care providers” and two for “patients”. The “patients” will be given brief notes on their “character”. A. Hamid: A 57-year-old man with large family. He has breathing and heart problems. He is not concerned with his smoking. He is unsure about whether he could quit if he tried. B. Lisa: A 25-year-old woman who is soon to marry. She wants to have a family. She wants to quit but is convinced that she can’t. If you are not selected for the role plays, please carefully watch them and make notes. 6. Evaluation (15 minutes) Everyone helps provide comments and feedback on the role plays. It is important to emphasize that you will develop your skills and confidence in delivering brief tobacco interventions with daily practice. Summary For those who are willing to quit, it is critical that you help them develop a quit plan for making a quit attempt and help them arrange follow-up contacts soon after the quit date. In order to deliver a full brief tobacco intervention effectively using the 5A’s and 5R’s models, it is important that you familiarize yourself with each step of the 5A’s and 5R’s and practise them in real-life situations.
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Module 7: Addressing non-smokers’ exposure to second-hand smoke Objectives Upon completion of this module participants will be able to: − describe the definition and dangers of second-hand smoke; − describe the brief intervention model for reducing non-smokers’ exposure to second-hand smoke; − role-play the brief intervention to address non-smokers’ exposure to second-hand smoke. Agenda 1. Levels of second-hand smoke exposure among non-smokers (15 minutes). 2. Definition of second-hand smoke (10 minutes). 3. Health effects of second-hand smoke (10 minutes). 4. The 5A’s brief intervention model for addressing non-smokers’ exposure to second-hand smoke (10 minutes). 5. Role-playing of a brief intervention to help non-smokers reduce second-hand smoke exposure (20 minutes). 6. Evaluation (15 minutes). Preparation 1. Levels of second-hand smoke exposure among non-smokers (15 minutes) Second-hand smoke exposure causes serious health problems in children and adult non-smokers. The only way to protect non-smokers fully is to eliminate smoking in all indoor spaces. In addition to supporting the comprehensive smoke-free laws in workplaces and public places, and supporting smokers to quit, health-care providers should also educate every non-smoker seen in a primary care setting about the dangers of second-hand smoke and help them avoid exposure to second-hand smoke. Questions: • Is second-hand smoke exposure common in your country? • How many people are exposed to second-hand smoke in your country?
Second-hand smoke exposure is common in many countries. Worldwide, it was estimated that 40% of children, 33% of male non-smokers, and 35% of female non-smokers were exposed to second-hand smoke in 2004. The highest proportions of people exposed were seen in European countries with high adult mortality (Belarus, Estonia, Hungary, Kazakhstan, Latvia, Lithuania, Republic of Moldova, Russian Federation, Ukraine) and countries in the WHO Western Pacific Region. More than 50% of children and adult non-smokers in those countries were exposed to second-hand smoke in 2004. You may find the prevalence of exposure to second-hand smoke in your country through local and national health authorities, who accumulate the data, or through published journal articles.
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Presentation 2. Definition of second-hand smoke (10 minutes) Brainstorming What is second-hand smoke?
Second-hand smoke (also called environmental tobacco smoke or passive smoking) is made up of − mainstream smoke, the smoke that is exhaled by the smoker; − side-stream smoke, the smoke that comes from the burning end of a cigarette or other tobacco products (pipe, cigar). 3. Health effects of second-hand smoke (10 minutes) Second-hand smoke is present in all indoor places where smoking is permitted, and there is no safe level of exposure. Second-hand smoke causes 600 000 premature deaths per year. Brainstorming What diseases are known to be caused by second-hand smoke?
Exposure to second-hand smoke adversely affects the health of children and adults. Figure 3 shows that second-hand smoke can cause the following diseases in children and adults: Diseases in children – – – – sudden infant death syndrome; acute respiratory illnesses; middle ear disease; chronic respiratory symptoms. Diseases in adults – – – – coronary heart disease; nasal irritation; lung cancer; reproductive effects in women (low birth weight).
4. The 5A’s brief intervention model for addressing non-smokers’ exposure to second-hand smoke (10 minutes) Primary care providers can take five steps (5As) to offer a brief intervention to educate non-smoking patients about the dangers of second-hand smoke and to protect themselves and their family from the effects of second-hand smoke:
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Ask –
Systematically identify non-smoking patients who are exposed to second-hand smoke at every visit. Advise – Advise the patient to avoid exposure to second-hand smoke. Assess – Determine the patient’s willingness to reduce exposure to second-hand smoke. Assist – Assist the patient in making an attempt to make his/her daily life environment smoke-free. Arrange – Schedule follow-up contacts.
Ask: We need to ask ALL of our non-smoking patients if they are exposed to second-hand smoke (Does anyone else smoke around you?) and record their responses. We make it part of our routine. Advise: We need to educate the patients about the dangers of second-hand smoke and advise them to avoid exposure to second-hand smoke. Your advice should be clear, positive and tailored to the particular patient’s characteristics and circumstances. For example, “There is no safe level of exposure, it is important that you avoid exposure to second-hand smoke, which may dramatically improve your respiratory symptoms.” Assess: We need to determine if the patient is willing to reduce his or her second-hand smoke exposure or not. We can also assess where the patient is exposed to second-hand smoke and whether there is a possibility to reduce the patient’s exposure. For example, if the patient is exposed to second-hand smoke at home, it is highly likely that the patient can reduce exposure by encouraging his or her family to quit or to smoke outside. Assist: If patients are willing to make an attempt to reduce their exposure to second-hand smoke then they will need some help from us. We need to assist patients in developing action plans for what they can do. Here are some examples to share with patients (MAD-TEA): • Meet friends at spaces in the community that are smoke-free. • Ask family members and visitors to smoke outside. • Declare their home and personal spaces (e.g. their car) to be smoke-free. • Talk to family members and the people they work with about the risks of second-hand smoke. • Encourage family members, friends and workmates who smoke to stop. • Advocate comprehensive smoke-free laws or regulations in workplaces and public places. Arrange: If the patient is willing to make an attempt, we should arrange follow-up after around one week to provide necessary support and talk to the patient about the matter again. Practice 5. Role-playing of a brief intervention to help non-smokers reduce second-hand smoke exposure (20 minutes) Practice is important for you to improve your confidence and skills in delivering a brief intervention to address second-hand smoke exposure. Volunteer to role play the 5A’s brief interventions in front of the group: • Volunteer 1 will be a doctor who attempts to address the patient’s second-hand smoke exposure. • Volunteer 2 will be a newly married female whose husband smoke at home.
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6. Evaluation (15 minutes) Each participant provides feedback/questions on volunteers’ role play of the brief tobacco interventions. Summary Exposure to second-hand smoke is common in many countries. There is no risk-free level of exposure to second-hand smoke. Primary care providers should routinely identify all patients who are exposed to second-hand smoke and advise them to avoid the effects of second-hand smoke. The 5A’s model can guide primary care providers to offer a brief intervention to address second-hand smoke in a primary care setting.
Module 8: Introduction to pharmacotherapy Objectives Upon completion of this module participants will be able to: − describe effective tobacco cessation medications; − prescribe the available range of NRT products; − recommend bupropion and varenicline appropriately; − apply tools to assess tobacco users’ levels of nicotine dependence; Agenda 1. Effective tobacco cessation medications (15 minutes). 2. Description of NRT products, bupropion and varenicline (25 minutes). 3. How to assess a tobacco user’s level of nicotine dependence (15 minutes). 4. Recommendations for use of NRT products in the treatment of tobacco dependence (15 minutes). 5. Prescribing NRT products (30 minutes). 6. Evaluation (20 minutes). Preparation 1. Effective tobacco cessation medications (15 minutes) Brainstorming What effective tobacco cessation medications are currently available for treating tobacco dependence in your country?
The currently available effective tobacco cessation medications are: − nicotine replacement therapy (NRT): nicotine gum, nicotine patches, nicotine nasal spray, nicotine inhaler, nicotine lozenges/sublingual tablets; − non-nicotine medications: bupropion sustained release (SR), varenicline, cytisine, clonidine, triptyline.
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Table 1 provides the effectiveness data for those tobacco cessation medications. According to USA clinical guidelines, NRT, bupropion and varenicline are first-line medications for treating tobacco dependence. Currently, NRT has the best balance of effectiveness, cost and safety. As a result, two forms of NRT (nicotine gum and nicotine patch) have been added to the WHO Model List of Essential Medicines. Presentation 2. Description of NRT products, bupropion and varenicline (25 minutes) Table 10 summarizes the information on NRT, bupropion and varenicline in terms of what those medications are, the purpose of using them, available dosage, advantages and disadvantages, general guidelines for using them, side-effects and warnings. 3. How to assess a tobacco user’s level of nicotine dependence (15 minutes) Assessing a tobacco user’s level of nicotine dependence can help primary care providers prescribe or recommend a dosage of NRT to tobacco users. There are two ways to assess the level of nicotine dependence: 3.1 Using the Fagerström Test This is the standard instrument for assessing the intensity of physical addiction to nicotine (Table 11). Scoring: 0−2 = very low dependence 3−4 = low dependence 5 = medium dependence 6−7 = high dependence 8−10 = very high dependence. Scores under 5: “Your level of nicotine dependence is still low. You should act now before your level of dependence increases.” Score of 5: “Your level of nicotine dependence is moderate. If you don’t quit soon, your level of dependence on nicotine will increase until you may be seriously addicted. Act now to end your dependence on nicotine.” Score over 5: “Your level of dependence is high. You are not in control of your smoking - it is in control of you! When you make the decision to quit, you may want to talk with your doctor about nicotine replacement therapy or other medications to help you break your addiction.” Results: Your score was:
. Your level of dependence on nicotine is:
.
Tobacco users whose level of dependence on nicotine is high or very high will be considered for a recommendation to use NRT.
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Table 11. Items and scoring for the Fagerström Test for nicotine dependence 1. How soon after you wake up do you smoke your first cigarette? Within 5 minutes 6−30 minutes 31−60 minutes After 60 minutes 2. Do you find it difficult to refrain from smoking in places where it is forbidden (e.g. in church, at the library, in the cinema, etc)? 3. Which cigarette would you hate most to give up? Yes No The first one in the morning All others 4. How many cigarettes per day do you smoke? 10 or less 11−20 21−30 30 or more 5. Do you smoke more frequently during the first hours after waking than during the rest of the day? 6. Do you smoke if you are so ill that you are in bed most of the day? Yes No Yes No Source: Heatherton TF et al. The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerstrom Tolerance Questionnaire. British Journal of Addiction, 1991; 86:1119−1127.
3 2 1 0 1 0 1 0 0 1 2 3 1 0 1 0
3.2 Asking two simple questions: • How many cigarettes do you smoke per day? A < 10 cpd; B 10−20 cpd; C 21−39 cpd; D > _ 40 cpd. • At what time do you smoke your first cigarette in the morning? A< _ 30 minutes after waking up; B > 30 minutes after waking up. 4. Recommendations for use of NRT products in the treatment of tobacco dependence (15 minutes) When you prescribe or recommend NRT products for tobacco users you will need to give them clear instructions and dosing recommendations. Instructions for use and dosing recommendations can be found in Table 10. Practice 5. Prescribing NRT products (30 minutes) Please work in small groups to recommend NRT treatment plans for two fictional smokers: Patient # 1: Kate is a 55-year-old married female who has smoked two packs per day for the past 40 years. She has tried to quit several times. The only medication she has ever tried was patches. She used a 21 mg patch in the past. She said, “they helped”, but she was never able to remain abstinent for more than two days because the cravings were so strong. She is interested in the patch. She reports smoking her first cigarette immediately after waking up. 57
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Please recommend a NRT treatment plan to Kate for the next several months. Patient # 2: Jack is a 35-year-old male who has smoked approximately 15 cigarettes per day for the past 20 years. He usually smokes his first cigarette about an hour after he wakes. After discussing all medication options, he has decided he does not want the patch and he doesn’t like pills. He is most interested in the lozenge. Please make a recommendation to Jack for prescribing the lozenge. 6. Evaluation (15 minutes) Each group presents its results. Everyone helps critique and give feedback. Below are suggested NRT treatment plans for Kate and Jack: Kate Nicotine patches Dose 21 mg 21 mg + 7mg 21 mg 14 mg 7 mg Jack Nicotine lozenge Dose 2 mg 2 mg 2 mg Quantity 10 lozenges per day 5 lozenges per day 2 lozenges per day Duration 6 weeks 3 weeks 3 weeks Quantity 2 patches per day (every morning) 1 patch of each per day 1 patch per day 1 patch per day 1 patch per day Duration 4 weeks 2 weeks 2 weeks 2 weeks 2 weeks
Summary There are several medications available for treating tobacco dependence. Currently NRT has the best balance of effectiveness, cost and safety. As a result, two forms of NRT (nicotine gum and nicotine patch) have been added to the WHO Model List of Essential Medicines. Dosing recommendation of NRT products should be made based on the tobacco user’s level of nicotine dependence.
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Table 10. Description of NRT, Bupropion and varenicline Advantages and disadvantages Side-effects and warnings • • • • Hiccups Jaw ache Stomach irritation Sore mouth Pros • Convenient/flexible dosing. • Faster delivery of nicotine than the patches. Dosing: Based on cigarettes/day (cpd) >20 cpd: 4 mg gum < _20 cpd: 2 mg gum Based on time to first cigarette of the day: Cons < _30 minutes = 4 mg • May be inappropriate for people with >30 minutes = 2 mg dental problems and those with Initial dosing is 1−2 pieces every 1−2 hours (10−12 temporomandibular joint (TMJ) pieces/day). syndrome. • Should not eat or drink 15 minutes Taper as tolerated. before use or during use. Duration: up to 12 weeks with no more than 24 pieces • Frequent use during the day is required to be used per day. to obtain adequate nicotine levels. How to use: It is not chewed like regular gum but rather is chewed briefly until you notice a “peppery” taste, then “parked” between cheek and gum for about 30 minutes. • Skin irritation • Allergy (not suitable if you have chronic skin conditions) • Vivid dreams and sleep disturbances General guidelines for use
Medication
Who can use
Purpose of use
Nicotine gum (OTC) Delivers nicotine through the lining of the mouth. Available dosage: 2mg, 4mg.
• Smokers 18 years • Withdrawal and over. symptom relief. • Smokers with • Control of severe heart and cravings/urges. circulation problems should start NRT under medical supervision. • Pregnant or breastfeeding women if they cannot stop without NRT.
Nicotine patch (OTC) Delivers nicotine through skin.
The same as nicotine gum.
• Withdrawal symptom relief. • Control of cravings/urges.
Available dosage: 24 hour delivery systems 7mg, 14mg, 21mg.
Pros Dosing (24 hour patch): • Achieve high levels of replacement. >40 cpd = 42 mg/day • Easy to use. 21−39 cpd = 28−35 mg/day • Only needs to be applied once a day. 10−20 cpd = 14−21 mg/day <10 cpd = 14 mg/day Cons If a dose > 42mg/day may be indicated, contact the • Less flexible dosing. patient’s prescriber. • Slow onset of delivery. Adjust based on withdrawal symptoms, urges, and • Mild skin rashes and irritation. comfort. After 4 weeks of abstinence, taper every 2 weeks in 7−14 mg steps as tolerated. Duration: 8−12 weeks. How to use: Patches may be placed on any hairless area on the upper body, including arms and back. Rotate the patch site each time a new patch is applied to lessen skin irritation.
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16 hour delivery systems 5mg, 10mg, 15mg.
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Medication Pros Dosing: • Easy to use. Based on time to first cigarette of the day: • Delivers doses of nicotine approxi< _30 minutes = 4 mg mately 25% higher than nicotine gum. >30 minutes = 2 mg Based on cigarettes/day (cpd) Cons >20 cpd: 4 mg • Should not eat or drink 15 minutes < _20 cpd: 2 mg before use or during use. Initial dosing is 1−2 lozenges every 1−2 hours (minimum of 9/day). Taper as tolerated. • Irritation of mouth • Irritation to stomach (nausea frequent 12−15%) • Hiccups • Heartburn Duration: up to 12 weeks with no more than 20 lozenges to be used per day. How to use: The lozenge should be allowed to dissolve in the mouth. It should not be chewed or swallowed. Pros • Flexible dosing. • Can be used in response to stress or urges to smoke. • Fastest delivery of nicotine of currently available products but not as fast as cigarettes. Cons • Nose and eye irritation is common, but usually disappears within one week. • Frequent use during the day required to obtain adequate nicotine levels. Dosing: 1 spray in each nostril, 1−2 times per hour (up to 5 times/hour or 40 times/day) Most average 14−15 doses/day initially Taper as tolerated. Duration: 3−6 months. • Nasal irritation (runny nose, sneezing, burning sensation) • Coughing • Nausea • Headache • Dizziness • Irritated throat
Who can use
Purpose of use Advantages and disadvantages General guidelines for use
Side-effects and warnings
Strengthening health systems for treating tobacco dependence in primary care / Part III
Nicotine lozenge (OTC) Delivers nicotine through the lining of the mouth while the lozenge dissolves. Available dosage: 2 mg, 4 mg.
The same as nicotine gum.
• Withdrawal symptom relief. • Control of cravings/urges.
Nicotine nasal spray (Rx) Delivers nicotine through the lining of the nose when sprayed directly into each nostril. Available dosage: 0.5 mg nicotine in 50 µl aqueous nicotine solution.
The same as nicotine gum plus those who do not have • Underlying chronic nasal disorders • Severe reactive airway disease.
• Withdrawal symptom relief. • Control of cravings/urges.
Participants’ workbook
Medication Advantages and disadvantages Pros • Flexible dosing. • Mimics the hand-to-mouth behaviour of smoking. • Few side effects. • Mouth or throat soreness or dryness • Coughing Duration: up to 6 months. Cons • Frequent use during the day required to obtain adequate nicotine levels. • Should not eat or drink 15 minutes before use or during use. Pros • Easy to use. • Pill form. • Few side-effects. • May be used in combination with NRT. Dosing: Take doses at least 8 hours apart. Start medication one week prior to the target quit date (TQD) 150 mg once daily for 3 days, then 150 mg twice daily for 4 days, then On TQD STOP SMOKING and continue at 150 mg twice Cons • Contraindicated with certain medical daily for 12 weeks May stop abruptly; no need to taper. conditions and medications. • Dry mouth • Nervousness/difficulty concentrating • Rash • Headache, dizziness • Seizures (risk is 1/1,000) Dosing: Minimum of 6 cartridges/day, up to 16/day Taper as tolerated (during the final 3 months of treatment). Side-effects and warnings
Who can use
Purpose of use
General guidelines for use
Nicotine inhaler (Rx) Delivers nicotine to the oral mucosa, not the lung, and enters the body much more slowly than the nicotine in cigarettes.
The same as nicotine gum plus those who do not have • Bronchospastic disease.
• Withdrawal symptom relief. • Control of cravings/urges.
Available dosage: 10 mg catridge delivers 4mg inhaled nicotine vapour.
Bupropion SR (Rx) Originally used as antidepressant. Affects the levels of neurotransmitters affecting the urge to smoke.
Available dosage: 150 mg sustained release tablet.
All adult smokers • Withdrawal except those symptom relief • Pregnant or breast(anxiety irritability feeding and depression). • Concomitant • Abstinence. therapy with medications or medical conditions known to lower the seizure threshold • Severe hepatic cirrhosis.
Warnings: advise patients to stop bupropion and contact a health-care provider immediately if they experience agitation, depressed mood, and any changes in behaviour that are not typical of nicotine withdrawal, or if they experience suicidal thoughts or behaviour. • Nausea • Sleep disturbances (insomnia, abnormal dreams) • Constipation • Flatulence • Vomiting Warnings: The same as for bupropion.
Strengthening health systems for treating tobacco dependence in primary care / Part III
Pros • Easy to use. • Pill form. • Generally well tolerated. • No known drug interactions. Cons • Nausea is common.
Varenicline (Rx) Attaches to nicotinic receptors. Part blocking the reward effects of nicotine and part stimulating the nicotinic receptors. Available dosage: 0.5 mg, 1 mg tablet.
All adult smokers • Withdrawal except those symptom relief. • Pregnant or breast- • Control of feeding cravings/urges. • Severe renal • Abstinence. impairment (dosage adjustment is necessary).
Dosing: Take with food. Start medication one week prior to the TQD 0.5 mg once daily X 3 days, then 0.5 mg twice daily X 4 days, then On TQD STOP SMOKING AND take 1.0 mg twice daily for 11 weeks. May stop abruptly; no need to taper.
Participants’ workbook
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Participants’ workbook
Module 9: Promoting brief tobacco interventions in the community Objectives Upon completion of this module participants will be able to: − identify outreach opportunities for delivering brief tobacco interventions to tobacco users in their homes or community settings; − identify referral resources within a local community for primary care provider to deliver brief tobacco interventions. Agenda 1. The opportunities for delivering brief tobacco interventions in a patient’s home and community (15 minutes). 2. Community referral resources for primary care providers to deliver brief tobacco interventions (15 minutes). 3. Compiling a list of available community resources for tobacco dependence treatment (20 minutes). 4. Evaluation (20 minutes). Preparation 1. The opportunities for delivering brief tobacco interventions in a patient’s home and community (15 minute) Everyone who uses tobacco should be advised to quit and primary care providers should use every encounter in both clinical settings and community settings as an opportunity to provide brief tobacco interventions to all patients who use tobacco to quit. Brainstorming What are the opportunities to deliver brief tobacco interventions in a patient’s home and community?
Primary care providers may have chances to conduct outreach activities in a patient’s home and community, which are the opportunities to deliver brief tobacco interventions to patients and their families. The common outreach activities for delivering brief tobacco interventions may include: − home visits to pregnant women, children and old people; − home visits to patients with severe chronic diseases; − home visits for family planning; − community health education; − environmental sanitation; − health screening; − data collection or survey in the community; − community public campaigns (such as World No Tobacco Day).
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Strengthening health systems for treating tobacco dependence in primary care / Part III
Participants’ workbook
Presentation 2. Community referral resources for primary care providers to deliver brief tobacco interventions (15 minutes) A community may have many existing resources to support primary care providers in delivering brief tobacco interventions to patients who use tobacco. The following community resources could be the referral resources for primary care providers when they deliver brief tobacco interventions: − tobacco quitlines; − specialist services in cessation clinics; − local tobacco cessation classes and support groups; − smoker’s web-based assistance; − free self-help materials. With community resources available to provide more in-depth assistance and follow-up, primary care providers will be freed up to focus on identifying and motivating tobacco users to quit, and may use a simplified brief tobacco intervention model called AAR (Ask, Advise, Refer). AAR brief tobacco intervention model 1. A 2. A 3. R Ask about tobacco use and document in the medical record. Advise patients who use tobacco to quit. “Quitting is one of the best things you can do for your health.” Refer to trusted resources. • For patients who are ready to quit, provide referral to resources (such as a quitline) that can provide assistance and follow-up. • For patients who are not ready to quit, provide referral to self-help materials, and let the patients know you are available to help when they are ready.
Practice 3. Compiling a list of available community resources for tobacco dependence treatment (20 minutes) A list of existing referral resources for tobacco dependence treatment in the community that your primary care organization serves will be a useful tool or resource to assist you in delivering brief tobacco interventions. Please work in small groups to create a list of available resources for tobacco dependence treatment in your community. 4. Evaluation (20 minutes) Each group should share its list of available community resources. Everyone adds to the discussion and gives feedback. Summary There are many opportunities for primary care providers to deliver brief tobacco intervention in patients’ homes and community. Communities also have referral resources available so that primary care providers may complement and extend their brief tobacco interventions by referring patients to those available community resources.
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REFERENCES AND RESOURCES 1. WHO Tobacco Free Initiative. The role of health professionals in tobacco control. Geneva, World Health Organization, 2005 (http://www.paho.org/English/AD/SDE/RA/bookletWNTD05.pdf, accessed 3 January 2010). 2. Primary health care in action (country profiles) (http://www.who.int/whr/2008/media_centre/country_profiles/en/index.html, accessed 3 January 2010). 3. The World Health Report 2008. Primary health care – now more than ever. Geneva, World Health Organization, 2008 (http://www.who.int/whr/2008/en/index.html, accessed 3 January 2012). 4. Lancaster T, Stead LF. Self-help interventions for smoking cessation. Cochrane Database of Systematic Reviews, 2005, (3):CD001118 (DOI: 10.1002/14651858.CD001118.pub2). 5. Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database of Systematic Reviews, 2008, (2):CD000165 (DOI: 10.1002/14651858.CD000165.pub3). 6. Nursing interventions for smoking cessation. Cochrane Database of Systematic Reviews, 2008, (1):CD001188 (DOI: 10.1002/14651858.CD001188.pub3). 7. Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database of Systematic Reviews, 2005, (2):CD001292 (DOI: 10.1002/14651858.CD001292.pub2). 8. Stead LF, Lancaster T. Group behaviour therapy programmes for smoking cessation. Cochrane Database of Systematic Reviews, 2005, (2):CD001007 (DOI: 10.1002/14651858.CD001007.pub2). 9. Stead LF, Perera R, Lancaster T. Telephone counselling for smoking cessation. Cochrane Database of Systematic Reviews, 2006, (3):CD002850 (DOI: 10.1002/14651858.CD002850.pub2). 10. Cahill K, Perera R. Quit and Win contests for smoking cessation. Cochrane Database of Systematic Reviews, 2008, (4):CD004986 (DOI: 10.1002/14651858.CD004986.pub3). 11. Stead LF et al. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews, 2008, (1):CD000146 (DOI: 10.1002/14651858.CD000146.pub3). 12. Gourlay SG, Stead LF, Benowitz N. Clonidine for smoking cessation. Cochrane Database of Systematic Reviews, 2004, (3):CD000058 (DOI: 10.1002/14651858.CD000058.pub2). 13. Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews, 2007, (1):CD000031 (DOI: 10.1002/14651858.CD000031.pub3). 14. Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database of Systematic Reviews, 2012, (4):CD006103 (DOI: 10.1002/14651858.CD006103.pub6). 15. Fiore MC et al. Treating tobacco use and dependence: 2008 update. Clinical practice guideline. Rockville, MD, Department of Health and Human Services, 2008. 16. Guidelines for implementation of Article 14 of the WHO FCTC. Geneva, World Health Organization Framework Convention on Tobacco Control, 2010 (http://www.who.int/fctc/protocol/guidelines/adopted/article_14/en/, accessed 27 April 2011). 17. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva, World Health Organization, 2009. 18. Oberg M et al. Worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries. Lancet, 2011, 377:139−146. 19. Global status report on noncommunicable diseases 2010. Geneva, World Health Organization, 2011 (http://www.who.int/nmh/publications/ncd_report_full_en.pdf, accessed 08 November 2011). 20. Myths and misconceptions about smoking. Sydney, Cancer Council Australia (http://www.cancer.org.au/cancersmartlifestyle/smokingandtobacco/mythsandmisconceptionsaboutsmoking.htm, accessed 08 November 2011). 21. Mahmud A, Feely J. Effect of smoking on arterial stiffness and pulse pressure amplification. Hypertension, 2003, 41(1):183−187. 22. The health consequences of smoking: nicotine addiction: a report of the Surgeon General. DHHS Publication No. (CDC) 88-8406. Washington, DC, Department of Health and Human Services, 1988. 23. The health benefits of smoking cessation. DHHS Publication No. (CDC) 90-8416. Washington, DC, Department of Health and Human Services, 1990. 64
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References and resources
24. Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’ observations on male British doctors. British Medical Journal, 2004, 328(7455):1519−1527. 25. The health consequences of smoking: a report of the Surgeon General. Washington, DC, Department of Health and Human Services, 2004. 26. How tobacco smoke causes disease: the Biology and behavioral basis for smoking-attributable disease: a report of the Surgeon General. Washington, DEC, Department of Health and Human Services, 2010. 27. Tobacco Atlas Online: costs to the economy (http://www.tobaccoatlas.org/costs.html, accessed 08 November 2011). 28. The tobacco atlas. 1st ed. Geneva, World Health Organization, 2002 (http://www.who.int/tobacco/resources/publications/tobacco_atlas/en/, accessed 21 October 2012). 29. Curbing the epidemic: governments and the economics of tobacco control. Washington, DC, The World Bank, 1999. 30. Tobacco control country profiles. 2nd ed. American Cancer Society, Inc., World Health Organization, and International Union Against Cancer, 2003 (http://www.who.int/tobacco/global_data/country_profiles/Introduction.pdf, accessed 08 November 2011). 31. Warren CW et al. Global Tobacco Surveillance System (GTSS) collaborative group. Patterns of global tobacco use in young people and implications for future chronic disease burden in adults. Lancet, 2006, 749–753. 32. Global Adult Tobacco Survey country reports and fact sheets. Geneva, World Health Organization, 2011 (http://www.who.int/tobacco/surveillance/gats/en/index.html, accessed 8 February 2012). 33. Tobacco: deadly in any form or disguise. Geneva, World Health Organization, 2006 (http://www.who.int/tobacco/communications/events/wntd/2006/Tfi_Rapport.pdf, accessed 13 September 2011). 34. Tobacco control country profiles. Geneva, World Health Organization (http://www.who.int/tobacco/surveillance/policy/country_profile/en/index.html, accessed 8 April 2012). 35. West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: an update. Thorax, 2000, 55(12), 987−999. 36. Henry-Edwards S et al. Brief intervention for substance use: a manual for use in primary care. (Draft version 1.1 for field-testing). Geneva, World Health Organization, 2003. 37. New Zealand smoking cessation guidelines. Wellington, Ministry of Health, 2007 (http://www.moh.govt.nz/moh.nsf/indexmh/nz-smoking-cessation-guidelines#availability, accessed 21 October 2012. 38. Younie L. Rapid assessment of readiness to change. Bristol, National Health Service (http://www.avon.nhs.uk/alcohol/pro/assessment.htm, accessed 08 November 2011). 39. Erkiliç TA. A discussion on the application of two factors: X and Y theories in the classroom management. American-Eurasian Journal of Scientific Research, 2008, 3(1):111−116. 40. Miller WR, Rollnick S. Motivational interviewing: preparing people to change addictive behavior. New York, NY, Guilford Press, 1991. 41. Motivational interviewing - a conversation of empathy and self-healing. Salt Lake City, UT, Able Differently (http://www.able-differently.org/PDF_forms/Motivational%20Interviewing.pdf, accessed 21 October 2012). 42. WHO/ISH Risk prediction charts for 14 WHO epidemiological sub-regions. orld Health Organization/International Society of Hypertension. (http://www.ish-world.com/Documents/colour_charts_24_Aug_07.pdf , accessed 8 November 2011). 43. WHO FCTC health warnings database (http://www.who.int/tobacco/healthwarningsdatabase/en/index.html, accessed 8 November 2011). 44. Quit tips. Singapore, Singapore Health Promotion Board (http://www.hpb.gov.sg/smokefree/article.aspx?id=458, accessed 8 November 2011). 45. Evaluating the effectiveness of smoke-free policies. IARC Handbook of Cancer Prevention, Vol. 13. Lyon, International Agency for Research on Cancer, 2009 (http://www.iarc.fr/en/publications/pdfs-online/prev/handbook13/, accessed 18 November 2011). 46. WHO report on the global tobacco epidemic, 2009: implementing smoke-free environments. Geneva, World Health Organization, 2009.
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References and resources
47. The truth about second-hand smoke. Edmonton, Alberta Health Services (http://www.albertahealthservices.ca/AddictionsSubstanceAbuse/hi-asa-truth-about-shs.pdf, accessed 18 November 2011). 48. WHO model lists of essential medicines. Geneva, World Health Organization, various dates (http://www.who.int/medicines/publications/essentialmedicines/en/index.html, accessed 8 December 2011). 49. Heatherton TF, Kozlowski LT, Frecker RC, Fagerström K. The Fagerström test for nicotine dependence: a revision of the Fagerström Tolerance Questionnaire. British Journal of Addiction, 1991, 86:1119−1127. 50. Mayo Clinic NDC tobacco dependence treatment medication summary (http://www.ndhealth.gov/tobacco/Businesses/MedicationHandout.pdf, accessed 8 December 2011). 51. Quinn VP. Community-based support services enhance smoking cessation programs. Sacramento, CA, California Center for Health Improvement, 1999. (http://www.chipolicy.org/pdf/Packard3.pdf, accessed 4 November 2011). 52. Schroeder SA. What to do with a patient who smokes. Journal of the American Medical Association, 2005, 294:482–487. 53. Child health programme review. Wellington, New Zealand Ministry of Health, 1998.
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Appendix: Sample evaluation form
APPENDIX: SAMPLE EVALUATION FORM Please select the answer you most agree with. Please also give your written feedback in the space provided. 1. Overall I found the training workshop useful for my work Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 2. Which part of the training workshop did you find the most useful?
3. Which part of the training workshop did you find the least useful?
4. The workshop facilitator had a good knowledge of the subject Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 5. The workshop facilitator’s skills in conveying the subject matter were good Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 6. As a result of my participation in the training workshop, I feel more confident to provide brief tobacco interventions to tobacco users Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 67
Strengthening health systems for treating tobacco dependence in primary care / Part III
Appendix: Sample evaluation form
7. How difficult did you find the training workshop? Too difficult Difficult Just right Easy Too easy 8. How could the workshop implementation be improved?
9. How could the training materials be improved?
10. Overall, how would you rate the workshop? Very good Good Average Poor Very poor 11. Any other comment, suggestion, criticism:
Thank you for your feedback!
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For further information, kindly contact PND as follows: Prevention of Noncommunicable Diseases (PND) World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland Tel.: + 41 22 791 21 11 Fax: + 41 22 791 48 32 Email: pnd@who.int http://www.who.int/tobacco/en/
WHO Library Cataloguing-in-Publication Data Strengthening health systems for treating tobacco dependence in primary care. Contents: Part I: Training for policy-makers: developing and implementing health systems policy to improve the delivery of brief tobacco interventions; Part II: Training for primary care service managers: planning and implementing system changes to support the delivery of brief tobacco interventions; Part III: Training for primary care providers: brief tobacco interventions; Part IV: Training for future trainers: applying adult education skills to training. 1.Tobacco use disorder - prevention and control. 2.Smoking - prevention and control. 3.Smoking cessation. 4.Primary health care. 5.Delivery of health care. 6.Capacity building. 7.Teaching materials. I.World Health Organization. ISBN 978 92 4 150541 3 (NLM classification: HD 9130.6)
© World Health Organization 2013 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int ) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int ). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/copyright_form/en/index.html ). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in France
Strengthening health systems for treating tobacco dependence in primary care Part IV: Training for future trainers: Applying adult education skills to training
Strengthening health systems for treating tobacco dependence in primary care / Part IV
Contents
CONTENTS
Part IV: Training for future trainers: Applying adult education skills to training .................................. 4 Introduction.................................................................................................................................................. 4 Facilitators’ guide ...................................................................................................................................... 6 Participants’ workbook ............................................................................................................................. 9 References and resources ......................................................................................................................... 15 Appendix 1: Teaching methods ................................................................................................................. 16 Appendix 2: Sample evaluation form........................................................................................................ 18
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PART VI: TRAINING FOR FUTURE TRAINERS: APPLYING ADULT EDUCATION SKILLS TO TRAINING
INTRODUCTION Part IV is designed to train future trainers who will be able to implement the WHO training package and provide further training to policy-makers, primary care service managers and primary care providers. The purpose of Part IV is to equip potential trainers with the basic knowledge, skills and tools in adult education, and to build their confidence to provide training on strengthening health systems for treating tobacco dependence in primary care. LEARNING OBJECTIVES, SKILL DEVELOPMENT AND OUTCOMES Learning objectives Upon completion of this training participants will be able to: − describe and apply principles of adult education; − describe and apply common adult teaching methods; − list the roles, characteristics and skills required to become an effective trainer; − develop and present a four-step lesson plan on a specific topic of strengthening health systems for treating tobacco dependence. Skills developed 1. Ability to apply principles of adult education in training. 2. Ability to apply common adult teaching methods in training. 3. Ability to develop four-step lesson plans to organize training activities. Outcomes A group of competent trainers are available to provide further training on strengthening health systems for treating tobacco dependence in primary care. STRUCTURE AND CONTENT The training for future trainers is designed as one module and consists of five topics on: the principles of adult education; learning style and adult teaching methods; skills and characteristics of effective trainers; preparation for training delivery; and effectively delivering training to adults. This training module is presented in a four-step format: preparation, presentation, practice and evaluation. The training workshop duration is around four hours. A sample agenda for the training workshop in half a day is provided below.
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Strengthening health systems for treating tobacco dependence in primary care / Part IV
Training for future trainers
Day 1 8:00 – 8:30 8:30 – 9:00 9:00 − 9:30 9:30 − 9:45 9:45 − 10:00 10:00 − 10:30 10:30 − 10:45 10:45 − 11:30 11:30 − 12:30 12:30 − 13:00 Welcome and Workshop Overview Participant introductions Principles of adult education Learning style and adult teaching methods Characteristics and skills of effective trainers Coffee break Preparation for training delivery: the four-step lesson plan How to effectively deliver training to adults Develop a four-step lesson plan on one selected topic in small groups Small group presentations Closing session Workshop evaluation
PREPARING FOR THE TRAINING The train-the-trainer workshop should ideally be delivered by two facilitators with detailed expertise in adult education and tobacco control. This workshop can be organized separately or in conjunction with any training for policy-makers, primary care service managers or primary care providers. The workshop should target those who have basic knowledge of adult education and medical education. They could be faculties of existing medical education institutions such as primary care providers’ field centres and on-the-job training centres at national or subnational level. It is recommended that the workshop should be conducted with a maximum of 20 participants. The workshop requires standard meeting/training tools and facilities, namely: − one main meeting room, with participants seated around small tables in small groups; − one or two additional break-out rooms if the large room cannot accommodate small group discussions; − flipcharts and markers (one for each small group); − projector and screen for presentations; − laptop computer with speakers for presentations; − presenter’s microphone; − portable microphones for discussions (optional). All the workshop training and background materials are provided online by WHO. These include: − the Facilitators’ guide; − presentations; − the Participants’ workbook; − workshop evaluation forms (see Appendix 2 for sample evaluation form). The References and Resources section contains hyperlinks to the relevant materials needed throughout the workshop. In addition to online materials, each participant should receive a binder or folder with key printed materials, particularly: − handouts of presentations; − key resource documents for each theme. The facilitators should ensure that key materials are available in the language of the participants.
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FACILITATORS’ GUIDE Duration Topic Objectives 4 hours Applying adult education skills to training Upon completion of this module, participants will be able to: − describe and apply principles of adult education; − describe and apply common adult teaching methods; − list the roles, characteristics and skills required to become an effective trainer; − develop and present a lesson plan on one topic of strengthening health systems for treating tobacco dependence.
Time
Facilitator activity
Participant activity
Audiovisual
Preparation 30 minutes Ask participants to brainstorm: Compared to children and teens, what are the special characteristics of adult learners? Write the responses on flipchart or whiteboard. Reinforce the responses and add to the list. Summarize the characteristics of adult learners: • Adults are autonomous and self-directed. • Adults are goal-oriented. • Adults are relevancy-oriented. • Adults are practical. • Adults have rich life experience and knowledge. • Adults need to be shown respect. State that, for each characteristic, there are implications for trainers. Use slides to present these implications/strategies that can be incorporated into effective training. Emphasize that, according to the special characteristics of adult learners, it is always best to actively involve adult learners in the educational process when they conduct training. Use slides to demonstrate the rates of retention for different teaching methods and conclude that the more actively engaged the learner is, the more learning takes place. Presentation 30 minutes Explain that different people have different learning styles. We shall need Participate in the to use a variety of teaching methods and a variety of teaching materials discussion. to accommodate different learners and learning styles. Anticipated list: Ask participants to think about teaching methods that were used during – lecture; this course and brainstorm a list of different instructional methods. – independent work; – brainstorming; Write responses on a flipchart or whiteboard. Reinforce the responses, – demonstration; elaborate on them, and add to the list if needed. – small group discussion or working in pairs; – role plays; – story-telling; – case study; – simulations. Ask: what are the advantages and limitations of each method? Participate in the discussion. Workbook, flipchart or whiteboard, PowerPoint presentation Part VI- B Volunteers share ideas about special characteristics of adult learners. Workbook, flipchart or whiteboard, PowerPoint presentation Part VI- A
Use slides to show the advantages and limitations of each adult teaching Refer to the workbook. method.
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Strengthening health systems for treating tobacco dependence in primary care / Part IV
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Presentation 20 minutes Ask participants to brainstorm: In addition to understanding the characteristics of adult learners and using a variety of adult teaching methods, what other skills, qualities and characteristics should an effective trainer have? Write the responses on flipchart or whiteboard Use slides to summarize the characteristics and skills of an effective trainer (the five E’s): – expertise; – eloquence; – empathy; – energy; – environmental engineering. Assign participants to review a checklist that includes these skills and qualities and place a check mark next to the items they feel they have mastered. Ask volunteers to share skill or qualities they have mastered. Volunteers share examples of skills mastered. Listen and ask questions. Workbook, PowerPoint presentation Part VI- D Share ideas and participate in discussion. Workbook, flipchart or whiteboard, PowerPoint presentation Part VI- C
20 minutes
Point out that organizing an actual training course requires addressing many practical considerations. One key thing that a trainer needs to work on is to develop a lesson plan for each specific topic/module. Refer participants to the Facilitators’ guides for training policy-makers, primary care service managers or primary care providers, and emphasize that the most effective method for organizing learning activities is to use four-step lesson plan: • Preparation: make participants ready to learn, reduce resistance and guarantee a foundation for the rest of the lesson. • Presentation: provide the content the learners need to understand: concepts and practice skills. • Practice and application: complete understanding has taken place only when the learner is able to apply or transfer the learning to new problems or situations. • Evaluation: the best way to predict whether the learners can perform the task that they have been taught. Testing can be informal, for example by observing the learners while they practise role plays, or formal by using tools such as a quiz. Demonstrate the structure of the lesson by asking participants to review one module in the Facilitators’ guide as an example of how a lesson is designed. State that participants will have an opportunity to use this structure to practise how to design a lesson plan.
20 minutes
Present ways to effectively deliver trainings to adults. Explain that, when we actually delivering the training, in addition to applying principles of adult education and using a variety of adult teaching methods, it is the trainer’s responsibility to: – define the purpose, objectives and time frames; – establish norms; – listen, guide the discussion, manage time and keep discussion on track; – maintain interest and encourage participation (motivating participants).
Learners listen and ask questions.
Workbook, PowerPoint presentation Part VI- E
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Strengthening health systems for treating tobacco dependence in primary care / Part IV
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Practice 60 minutes Assign participants to small groups to: • Develop a lesson plan on one selected topic using the above mentioned lesson plan structure of: – preparation; – presentation; – practice; – evaluation. • Prepare a 10−15 minute presentation to present the group’s lesson plan. Check in with groups during this planning stage to support and answer questions. Evaluation 60 minutes Ask participants to share presentations. Everyone gives feedback. Participants deliver presentations and give feedback. Work in a small group to develop a lesson plan and prepare a presentation on their lesson plan. Workbook, PowerPoint presentation Part VI- F
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PARTICIPANTS’ WORKBOOK Objectives Upon completion of this module participants will be able to: − describe and apply principles of adult education; − describe and apply common adult teaching methods; − −list the roles, characteristics, skills required to become an effective trainer; − develop and present a four-step lesson plan on a specific topic of strengthening health systems for treating tobacco dependence. Agenda 1. Principles of adult education (30 minutes). 2. Learning styles and adult teaching methods (30 minutes). 3. Skills and characteristics of effective trainers (20 minutes). 4. Preparation for training delivery (20 minutes). 5. Effectively deliver trainings to adults (20 minutes). 6. Developing a four-step lesson plan (60 minutes). 7. Presenting the lesson plan (60 minutes). Preparation 1. Principles of adult education (30 minutes) Brainstorming Compared to children and teens, what are special characteristics of adult learners?
Special characteristics of adult learners: • Adults are autonomous and self-directed. • Adults have accumulated a foundation of life experience and knowledge. • Adults are goal-oriented. • Adults are relevancy-oriented. • Adults are practical. • Adults need to be shown respect. For each characteristic, there are implications for you, the trainer (Table 1).
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Strengthening health systems for treating tobacco dependence in primary care / Part IV
Participants’ workbook
Table 1. How the characteristics of learners influence teaching strategies Characteristics of adult learners 1. Adult learners are autonomous and self-directed Teaching strategies • Involve participants. • Serve as facilitator. • Determine the interests of learners. • Recognize expertise of participants. • Encourage participants to share their experience and knowledge. • Have clear objectives. • Explain how training objectives relate to training activities. • Let participants choose topics that reflect their own interests. • Show the relevance of training to their jobs. • Give them opportunity to practise the new skills. • Focus on teaching practical skills/tools, methods. • Acknowledge the wealth of knowledge and experience the participants bring to the training. • Treat the participants as equals rather than subordinates. • Allow participants to voice their opinions freely in class.
2. Adult learners have a foundation of life experience and knowledge 3. Adult learners are goal-oriented 4. Adult learners are relevancy-oriented 5. Adult learners are practical 6. Adult learners need to be respected
The special characteristics of adult learners suggest that we should actively engage learners in the learning process using various participatory teaching methods. The average learning retention rates of the different teaching methods shown below (Table 2) imply that the more actively engaged the learner is, the more learning takes place. Table 2. Learning retention rates of teaching methods Teaching methods Passive teaching methods Lecture Reading Audiovisual Demonstration Participatory teaching methods Discussion group Practice by doing Teaching others Average learning retention rates 5% 10% 20% 30% 50% 75% 90%
Presentation 2. Learning styles and adult teaching methods (30 minutes) While different people think and learn differently, there are four basic learning styles (Table 3). Most people are predominantly one type of learner, but usually they can adapt to another style.
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Strengthening health systems for treating tobacco dependence in primary care / Part IV
Participants’ workbook
Table 3. Teaching strategies for learning styles Learning styles Visual learners Characteristics Process new information best when it is visually illustrated or demonstrated Process new information best when it is spoken Process new information best when it can be touched or manipulated Remember best when they DISCUSS with others the new and complex information they are learning Teaching strategies – graphics, illustrations – images – demonstrations – lectures – discussions – written assignments, taking notes – examination of objects – participation in activities – participation in activities – discussions
Auditory learners Kinesthetic learners
Verbal learners
A training course that uses a variety of teaching methods to accommodate different learning styles will increase the likelihood of learner success in the course. Brainstorming What are common adult teaching methods?
What are the advantages and limitations of each method? Method Lecture Socratic questioning Independent work Brainstorming Demonstration Small group discussion or working in pairs Role plays Story-telling Case study Simulations Advantages Limitations
(See details in Appendix 1)
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Strengthening health systems for treating tobacco dependence in primary care / Part IV
Participants’ workbook
3. Skills and characteristics of effective trainers (20 minutes) Brainstorming What skills, qualities and characteristics an effective trainer should have?
The characteristics and skills of an effective trainer can be summarized as five Es (expertise, eloquence, empathy, energy and environmental engineering). Exercise: Please review the checklist for the five Es and place a check mark next to the items you feel you have mastered. Skills/characteristics Expertise The power of knowledge and learning Involve participants. Understands and uses adult learning principles to facilitate learning Creates a big picture “container” before getting involved in details Integrates and summarizes key learning points Debriefs to verify understanding and ensure embedding of learning Responds to questions and comments appropriately. The power of language and organization Adapts speech to the needs of multilingual learners Provide clear, easy-to-follow instructions Presents information in clear, concrete and colourful language Transitions skillfully from one topic to another Encourages participation by using appropriate questions. The power of understanding and consideration Understands and manages personal preferences and style Understands learners’ needs and expectations Adapts instruction to the learner’s level of experience and skill Gives participants positive reinforcement and constructive feedback. The power of commitment and animation Shows passion and interest for the subject Is animated and uses appropriate tempo and voice volume Energizes the group and makes learning enjoyable. The power of managing the learning environment Creates a brain-affirming atmosphere Ensures good space, light and working areas Manages time and prioritizes content effectively Uses all equipment and tools skillfully.
Eloquence
Empathy
Energy
Environmental engineering
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Strengthening health systems for treating tobacco dependence in primary care / Part IV
Participants’ workbook
4. Preparation for training delivery (20 minutes) A good trainer has to thoroughly prepare beforehand. Generally the professional advice given states that for every hour that you are training you should have completed 10 hours of study and preparation. Before training delivery, many practical considerations need to be addressed. One of the key things is for trainers to develop a lesson plan to organize learning activities on each training module. The content, process and teaching methods will be specified in the lesson plan to guide the training delivery. The most effective method for organizing learning activities is to use a four-step lesson plan, which is also the most effective format for ensuring that you provide sufficient opportunity for your participants to practise their newly learned skills. The four steps are: • Preparation (help your learners be prepared to learn): − list the objectives to be learned; − reduce resistance; − ask challenging or engaging questions; − administer a pretest; − begin with an exercise or management game; − tell a story or set up a mystery; − ask participants for their objectives. • Presentation (provide the content the learners need to understand: concepts and practice skills): − use a variety of teaching methods and teaching aids. • Practice (complete understanding has taken place only when the learner is able to apply or transfer the learning to new problems or situations): − Socratic review; − written exams; − oral tests; − role-playing; − problem-solving exercises; − case studies; − simulations. • Evaluation (the best way to predict whether the learners can perform the task that they have been taught): − Socratic dialogue; − written or oral responses to projects; − tests; − problem-solving projects; − practice in simulated circumstances; − role-playing and other performances.
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Strengthening health systems for treating tobacco dependence in primary care / Part IV
Participants’ workbook
Examples of a four-step lesson plan: Please refer to any module contained in the Facilitators’ guides for training policy-makers, primary care service managers, or primary care providers and review how a lesson is designed. 5. Effectively deliver training to adults (20 minutes) In addition to using a variety of teaching methods and teaching aids, it is the trainer’s responsibility to: − define the purpose, objectives, and time frames; − establish norms; − listen, guide the discussion, manage time and keep the discussion on track; − maintain interest and encourage participation (motivating participants). Table 4 provides a model for promoting the motivation of participants. Table 4. A model for promoting participants’ motivation Relevance Enjoyment Volition Value Success Make it relevant to their reality (work, career or life). Make it fun and enjoyable, but not games for games sake. Give them choices about what, how, where and when for the learning. Make it valuable to them and match their values and mental maps. Help them be successful in the activities you design for them; don’t set them up to fail. Create a high-challenge/low-threat environment.
Practice 6. Developing a four-step lesson plan (60 minutes) Work in small groups to: • Develop a lesson plan on one selected topic using the above-mentioned lesson plan structure of: − preparation; − presentation; − practice; − evaluation. • Prepare a 10−15 minute presentation to present your lesson plan. Your lesson should include a preparation activity, a brief presentation, a period of practice and evaluation. Be prepared to present your lesson plan to the large group in 10−15 minutes. Evaluation 7. Presenting the lesson plan (60 minutes) Each group shares its lesson plan. Everyone adds to the discussion and gives feedback.
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REFERENCES AND RESOURCES 1. Rusell SS. An overview of adult learning processes. Urologic Nursing, 2006, 26(5):349−370. 2. Effective teaching strategies (http://www.cdc.gov/healthyyouth/foodsafety/pdf/effec-tive_teaching_strategies.pdf, accessed 8 November 2011). 3. Adult learners (http://online.rit.edu/faculty/teaching_strategies/adult_learners.cfm, accessed 8 November 2011). 4. Mitchell C. The trainer’s handbook. The AMA guide to effective training. New York, NY, American Management Association, 1997. 5. Choosing and using the right instructional methods and training activities (http://www.thetrainingworld.com/faq/indexmethods.htm, accessed 8 November 2011). 6. Babcock DE, Miller MA. (1994). Client education: theory and practice. St. Louis, MO, Mosby, 1994. 7. Methods of instruction (http://www.drillpad.net/DP_IRL_MOI.htm, accessed 8 November 2011). 8. Facilitating learning: teaching and learning methods (http://www.faculty.londondeanery.ac.uk/e-learning/small-group-teaching/Facilitating_learning_ teaching_-_learning_methods.pdf, accessed 8 November 2011). 9. Techniques (http://www.inquiry.net/adult/trainer/techniques.htm, accessed 8 November 2011). 10. Designing effective learning programmes: a brain based approach to motivate and engage learners. Geneva, PLB Consulting Ltd., 2007.
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Strengthening health systems for treating tobacco dependence in primary care / Part IV
Appendix 1: Teaching methods
APPENDIX 1: TEACHING METHODS Method
Advantages • Can accommodate a large group of students. • Provides new or complex information that may be difficult for participants to find quickly on their own. • Can be fully prepared ahead of time. • Encourages active participation. • Provides an opportunity for learners to articulate facts, thoughts and feelings. • Provides an opportunity for problem-solving
Limitations • Trainer-focused, not learnerfocused. • Does not tap into learner’s higher thinking or problemsolving. • Participants may not remember and/or understand the content. • Requires trainer to manage discussion to keep learners on task to meet objectives. • Requires learners to have enough to knowledge to participate. • May be difficult for quiet/shy learners or learners who lack knowledge. • Learners who are not prepared may go unnoticed.
Rules and tips • Give a clear introduction and summary. • Include examples, analogies. • Use visuals when needed to enhance meaning. • Be prepared for questions and prepare responses in advance.
Lecture
Socratic questioning
• Prepare learners in advance so they can participate in the discussion. • Requires question outline and prompts to stimulate responses. • Trainer should prepare anticipated answers to questions. • Keep objectives in mind so that you can keep discussion productive. • Provide positive feedback during the discussion. • Paraphrase/repeat main points to reinforce learning. • Manage interactions during the discussion. • Set goals and objectives for independent work. • Ensure that the problem is related to the learner’s specific needs. • Ensure that learners are prepared with information and resources and get support. • Provide opportunity for learners to share their work to get feedback. • Two facilitators work in pairs. One reads the question and invites participants to offer ideas. The other writes down the ideas. • All ideas are accepted and NO criticism, discussion or questions are allowed until after the brainstorm is over. • The wilder the better. Have fun. Be creative. • Clearly state the objectives of the demonstration. • Use the actual equipment whenever it is practical. • Always demonstrate the skill correctly and determine whether it will be a better learning experience to show the whole activity/skill at once or in parts. • Ensure that all learners can see and hear all the steps. • Provide the opportunity for learners to practise the skill.
Independent work
• Active learner participation. • Encourages higher thinking and problem-solving. • Learners can work at their own pace and focus on specific learning needs.
• Not all learners understand the assignment, actively participate and achieve learning objectives. • Limits collaboration and mixing of ideas.
Brainstorming
• Creativity and generation of new ideas. • Friendly competition and mutual help. • Encourages all learners to participate because all ideas are equally accepted.
• Not all learners may feel comfortable or safe. • Requires experienced facilitators, otherwise the activity can become messy, chaotic and may cause conflict.
Demonstration
• Makes the explanation of the • May require additional complex information or a skill resources to perform. more concrete. • Requires a high degree of • Sets the standard of trainer skill. performance expected of • Restricted to small groups. the trainee. • Trainer can serve as a role model. • Learners can see practical application of concepts.
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Strengthening health systems for treating tobacco dependence in primary care / Part IV
Appendix 1: Teaching methods
Method
Advantages
Limitations
Rules and tips • Prepare a task that can benefit from teamwork in the classroom and the real setting. • Ask each group to select a moderator/leader (to guide discussion) and a recorder. • Provide a warm, supportive and nonthreatening environment. • Circulate to support small groups. • Provide opportunity for small groups to share their work to get feedback and learn from each other. • Provide detailed information for the learner to understand the scenario and to: – set the scene and conditions; – describe characters, or ask learners to build characters; – describe the challenge or the problem. • Ask 2−3 volunteers to do a role play of no more than 10 minutes. • Thank the role-players. • Invite feedback, summarize the experience and link with learning objectives. • Build stories, either real case studies or fictional, that are relevant to the audience. • Build a story that fits one or more of the following situations: – describe what happens to create a change; – describe the consequences, and the resolution; – show how to perform action steps; – show how concepts can be operationalized. • Define the case clearly for the learner. • Create case studies based on realistic situations. • Act as a mediator for the discussion, provide guidance on the process. • Show how the case study illustrates application of knowledge or skills. • Ensure learners understand the purpose of the simulation. • Simulation exercises need to be easily recreated and be the same experience for each learner. • Provide learners with feedback about their performance.
Small group • Promotes collaboration. • Some learners may dominate discussion or • Trainees are often more the discussion. working in pairs. comfortable in small groups, • Some learners may be even quiet/shy learners can unprepared to participate actively participate and share actively, and may get off ideas. track without good facilitation. • Learners can share ideas • Requires more classroom in a more deep and profound time than large group way. discussion. Role plays • Provides safe opportunity to practise. • Provides opportunity for learners to assume roles of others and thus appreciate another point of view. • Can clarify complex information. • May be uncomfortable for some learners. • Not appropriate for large groups. • Requires debriefing afterwards to ensure objectives were met. This can be time-consuming.
Story-telling
• More engaging than lecture. • Not effective for • Illustrates practical application communicating deep, of concepts. skills-based knowledge. • Effective for cognitive or • Trainer must make a clear affective objectives. connection between story • Effective for relaying new and objectives. or complex information. • Can be combined with other teaching methods. • Provides a safe opportunity to practise skills and build confidence. • Learners see practical application of concepts. • Promotes problem solving. • Can clarify complex information. • Learners get a clear understanding about what is expected of them. • Allows learners to see the practical application of concepts. • Can clarify complex information. • Allows learners the opportunity to practise skills in a safe environment. • Some learners may not see relevance to own situation. • Insufficient information can lead to inappropriate results. • Requires debriefing afterwards to ensure objectives were met. This can be timeconsuming. • May be uncomfortable for some learners. • Requires trainer to take the time to ensure that learners understand the assignment and perform the skill correctly. • Requires debriefing afterwards to ensure objectives were met. This can be timeconsuming. • May require additional resources to perform.
Case study
Simulations
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Strengthening health systems for treating tobacco dependence in primary care / Part IV
Appendix 2: Sample evaluation form
APPENDIX 2: SAMPLE EVALUATION FORM Please select the answer you most agree with. Please also give your written feedback in the space provided. 1. Overall I found the training workshop useful for my work Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 2. Which part of the training workshop did you find the most useful?
3. Which part of the training workshop did you find the least useful?
4. The workshop facilitator had a good knowledge of the subject Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 5. The workshop facilitator’s skills in conveying the subject matter were good Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 6. As a result of my participation in the training workshop, I feel more confident to provide training on strengthening health systems for treating tobacco dependence in primary care Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 18
Strengthening health systems for treating tobacco dependence in primary care / Part IV
Appendix 2: Sample evaluation form
7. How difficult did you find the training workshop? Too difficult Difficult Just right Easy Too easy 8. How could the workshop implementation be improved?
9. How could the training materials be improved?
10. Overall, how would you rate the workshop? Very good Good Average Poor Very poor 11. Any other comment, suggestion, criticism:
Thank you for your feedback!
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For further information, kindly contact PND as follows: Prevention of Noncommunicable Diseases (PND) World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland Tel.: + 41 22 791 21 11 Fax: + 41 22 791 48 32 Email: pnd@who.int http://www.who.int/tobacco/en/
WHO Library Cataloguing-in-Publication Data Strengthening health systems for treating tobacco dependence in primary care. Contents: Part I: Training for policy-makers: developing and implementing health systems policy to improve the delivery of brief tobacco interventions; Part II: Training for primary care service managers: planning and implementing system changes to support the delivery of brief tobacco interventions; Part III: Training for primary care providers: brief tobacco interventions; Part IV: Training for future trainers: applying adult education skills to training. 1.Tobacco use disorder - prevention and control. 2.Smoking - prevention and control. 3.Smoking cessation. 4.Primary health care. 5.Delivery of health care. 6.Capacity building. 7.Teaching materials. I.World Health Organization. ISBN 978 92 4 150541 3 (NLM classification: HD 9130.6)
© World Health Organization 2013 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int ) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int ). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/copyright_form/en/index.html ). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Printed in France
Strengthening health systems for treating tobacco dependence in primary care Part II: Training for primary care service managers: Planning and implementing system changes to support the delivery of brief tobacco interventions
Strengthening health systems for treating tobacco dependence in primary care / Part II
Contents
CONTENTS
Part II: Training for primary care service managers: Planning and implementing system changes to support the delivery of brief tobacco interventions ................................................. 3 Introduction.................................................................................................................................................. 3 Facilitators’ guide ...................................................................................................................................... Module 1: Setting the stage for increasing access to tobacco dependence treatment in primary care....................................................................................................................... Module 2: The service managers’ role in promoting brief tobacco interventions in primary care....................................................................................................................... Module 3: Integrating brief tobacco interventions into existing infrastructure............................... Module 4. Getting support from stakeholders..................................................................................... Module 5: Community participation ...................................................................................................... Module 6: Sustaining a system change: feedback, motivations and incentives.............................. Module 7: Your action plan to implement a system change .............................................................. Participants’ workbook ............................................................................................................................. Module 1: Setting the stage for increasing access to tobacco dependence treatment in primary care....................................................................................................................... Module 2: The service managers’ role in promoting brief tobacco interventions in primary care....................................................................................................................... Module 3: Integrating brief tobacco interventions into existing infrastructure............................... Module 4. Getting support from stakeholders..................................................................................... Module 5: Community participation ...................................................................................................... Module 6: Sustaining a system change: feedback, motivations and incentives.............................. Module 7: Your action plan to implement a system change .............................................................. 7 7 8 10 11 14 15 17 19 19 27 33 39 45 49 53
References and resources ......................................................................................................................... 57 Appendix: Sample evaluation form ....................................................................................................... 59
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PART II: TRAINING FOR PRIMARY CARE SERVICE MANAGERS: PLANNING AND IMPLEMENTING SYSTEM CHANGES TO SUPPORT THE DELIVERY OF BRIEF TOBACCO INTERVENTIONS
INTRODUCTION Primary care service managers are policy takers. They have responsibilities and managerial roles in changing all components of health systems and involving communities to support the provision of brief tobacco interventions as part of primary care providers’ routine practice. The purpose of Part II is to improve primary care service managers’ knowledge, skills and confidence for designing and implementing effective system changes to improve the integrated delivery of brief tobacco interventions in primary care settings. LEARNING OBJECTIVES, SKILL DEVELOPMENT AND OUTCOMES Learning objectives Upon completion of this training participants will be able to: − articulate the rationale for implementing system changes in a primary care setting; − describe why primary care service managers are positioned to plan and implement system changes for treating tobacco dependence; − apply the WHO Health System Framework as a tool to diagnose system problems/constraints and to plan system changes to address them; − identify opportunities to integrate brief tobacco interventions into existing primary care services; − integrate brief tobacco interventions into existing primary care facility infrastructure; − identify and solicit support from stakeholders, policy-makers and champions in organizations and the community; − develop an action plan to strengthen primary care systems to improve the delivery of brief tobacco interventions using the WHO building blocks. Skills developed 1. Ability to use the WHO Health System Framework to diagnose system constraints to delivering brief tobacco interventions in primary care settings. 2. Ability to identify appropriate system level interventions to motivate and support primary care providers to routinely provide brief tobacco interventions. 3. Ability to effectively engage all stakeholders to support and sustain the system changes in their organization. 4. Ability to develop an action plan for implementing the new system interventions. Outcomes 1. Increased technical capacity of primary care service managers in planning and implementing system changes to support the delivery of brief tobacco interventions in primary care settings. 2. Concrete action plans made by participants for strengthening their primary care systems to improve the delivery of brief tobacco interventions.
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Training for primary care service managers
STRUCTURE AND CONTENT The training for primary care service managers consists of seven modules. Each of the seven modules addresses a specific issue or phase of the process of identifying and implementing system changes to support the delivery of brief tobacco interventions in primary care settings. Each training module is presented in a four-step format, namely: preparation, presentation, practice and evaluation. The modules are summarized below. Further guidance for facilitators follows in the detailed Facilitators’ guide. Module 1: Module 2: Module 3: Module 4: Module 5: Module 6: Module 7: Setting the stage for increasing access to tobacco dependence treatment in primary care. The service managers’ role in promoting brief tobacco interventions in primary care. Integrating brief tobacco interventions into existing infrastructure. Getting support from stakeholders. Community participation. Sustaining a systems change: feedback, motivations and incentives. Your action plan to implement a system change.
If all seven modules are used, the training workshop duration is 2.5 days. However, the duration and detail covered in each module should be adapted to the needs of the participants. Their needs will depend on their experience and knowledge of the issue, the stage of WHO FCTC implementation in the country, and the infrastructure, strengths and weaknesses of their health system. A sample agenda for the training workshop of 2.5 days is provided below. Day 1 8:30 – 9:00 9:00 – 9:30 9:30 – 9:50 9:50 − 10:30 10:30 − 10:45 10:45 − 12:15 12:15 − 13:15 13:15 − 15:30 15:30 − 16:00 16:00 − 17:15 17:15 − 17:30 Registration Welcome and Workshop Overview Participant introductions Pre-course assessment Module 1: Setting the stage for increasing access to tobacco dependence treatment in primary care (1) Coffee break Module 1: Setting the stage for increasing access to tobacco dependence treatment in primary care (2) Lunch Module 2: The service managers’ role in promoting brief tobacco interventions in primary care Coffee break Module 3: Integrating brief tobacco interventions into existing infrastructure (1) Daily wrap-up
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Training for primary care service managers
Day 2 8:30 – 9:00 9:00 − 9:45 9:45 − 10:30 10:30 − 10:45 10:45 − 12:15 12:15 − 13:15 13:15 − 15:15 15:15 − 15:45 15:45 − 17:30 17:30 − 17:45 Day 3 8:30 – 9:00 9:00 − 10:30 10:30 − 10:45 10:45 − 12:30 12:30 − 13:00 Interactive discussions Module 7: Your action plan to implement a system change (1) Coffee break Module 7: Your action plan to implement a system change (2) Closing session Workshop evaluation Interactive discussions Module 3: Integrating brief tobacco interventions into existing infrastructure (2) Module 4: Getting support from stakeholders (1) Coffee break Module 4: Getting support from stakeholders (2) Lunch Module 5: Community participation Coffee break Module 6: Sustaining a systems change: feedback, motivations and incentives Daily wrap-up
PREPARING FOR THE TRAINING Organizing a training workshop requires many practical considerations to be addressed, such as when and where the training will be provided, forming a facilitation team, setting up a workshop programme and agenda, selecting participants, and logistics and materials. The facilitation team The training should be delivered by an expert facilitation team identified by the organizer in consultation with key local partners. The team should include: − a lead facilitator with detailed expertise in treatment of tobacco dependence and health systems and experience in facilitating workshops; − one or two additional facilitators with expertise in one or more aspects of tobacco control, medical education, health system and policy; − additional content presenters as necessary. The facilitation team should be supported by one or more logistics assistants to facilitate logistical needs during the workshop, including production and reproduction of materials. Workshop programme and schedule Prior to the training, the organizer and facilitators should gather as much information as possible about the country situation and the knowledge, skills and needs of participants in order to determine the training content and structure. If necessary, adjustments can be made to the content and structure to suit the situation. The organizer and facilitators will then need to design an appropriate training schedule or agenda based on the content they want to offer to the participants, the time needed for each module and the overall timeframe of the workshop. Please try to avoid creating an overcrowded schedule during the planning of the schedule. 5
Strengthening health systems for treating tobacco dependence in primary care / Part II
Training for primary care service managers
Selecting participants The workshop is targeted at those who are concerned with the planning and provision of primary care services and with managing performance. These could be managers of community hospitals, general practitioners (GPs) or community health services (e.g. the director of a community hospital, outpatient department heads, managers of health programmes dealing with NCDs, tuberculosis and maternal and child health). They could be health-care workers, but normally they do not provide primary care services to clients directly. It is recommended that the workshop be conducted with a maximum of 20 participants. Logistics The workshop requires standard meeting/training tools and facilities, namely: − one main meeting room, with participants seated around small tables in small groups; − one or two additional break-out rooms if the large room cannot accommodate small group discussions; − flipcharts and markers (one for each small group); − projector and screen for presentations; − laptop computer with speakers for presentations; − presenter’s microphone; − portable microphones for discussions (optional); − desktop computer, printer and photocopier for document production during the workshop (optional). Materials All the workshop training and background materials are provided online by WHO. These include: − the Facilitators’ guide; − presentations; − the Participants’ workbook; − workshop evaluation forms (see Appendix for sample evaluation form). The References and Resources section contains hyperlinks to the relevant materials needed throughout the workshop. In addition to online materials, each participant should receive a binder or folder with key printed materials, particularly: − handouts of presentations; − key resource documents for each theme. The facilitation team should decide which resources are most relevant to the participants and should include them in the printed materials. The facilitation team should also ensure that key materials are available in the language of the participants.
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FACILITATORS’ GUIDE Module 1: Setting the stage for increasing access to tobacco dependence treatment in primary care Duration Objectives 1 hour and 50 minutes Upon completion of this module, participants will be able to: − recognize the burden of tobacco use and the potential of tobacco cessation to save lives; − articulate the rationale for identifying and offering help to tobacco users in primary care settings; − describe what tobacco dependence treatment should be routinely offered in primary care; − describe at least three brief tobacco intervention models; − role-play a brief tobacco intervention model. Facilitator activity Participant activity Audiovisual
Time
Preparation 20 minutes Ask participants to identify and share three problems that tobacco use causes in their community. Facilitate a discussion about the burden of tobacco use in terms of health, quality of life, and money. Present the potential of tobacco cessation to save lives. Emphasize that countries concerned with health gains in the shortto medium-term should consider promoting treatment of tobacco dependence as part of any comprehensive tobacco control strategy, as reflected in the WHO FCTC. Identify three problems and volunteer to share them with the group. Refer to the workbook and participate in the discussion. Anticipated response: participants agree that it is important to dedicate resources to treat tobacco dependence as part of a comprehensive tobacco control strategy. Flipchart, PowerPoint presentation Part IIModule 1-A
Presentation 20 minutes Emphasize that primary care is the first level of contact of individuals, the Refer to the workbook.. Flipchart, family and community for health care. Thus it is an ideal place to identify PowerPoint and treat tobacco users. presentation Facilitate discussion about which tobacco dependence treatments Refer to the workbook Part IIModule 1-B should be routinely offered in primary care? and participate in the Explain that: • The guidelines for implementing Article 14 of the WHO FCTC recommend that: − all Parties should aim to develop a comprehensive system to provide a range of interventions for tobacco cessation and treatment of tobacco dependence; − if Parties cannot provide comprehensive treatment simultaneously, they should use a stepwise approach and start with providing brief tobacco interventions to all tobacco users. • In line with the Article 14 guidelines, WHO recommends that health systems should at least deliver brief tobacco interventions as part of routine services in primary care. Emphasize that this training will focus on how to strengthen health systems to improve the delivery of brief tobacco interventions by primary care providers. discussion.
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Presentation 15 minutes State that primary care providers can help patients successfully quit tobacco by offering interventions as short as three minutes, and that there are several structured models available to help them deliver these brief tobacco interventions. Refer participants to the workbook and use PowerPoint slides to give an overview of these brief tobacco intervention models: • 5A’s: Ask, Advise, Assess, Assist, Arrange. • 5R’s: Relevance, Risks, Rewards, Roadblocks, Repetition. • AAR: Ask; Advise; Refer. • AAA: Ask, Advise, Act. 10 minutes Use a three-minute video to demonstrate the 5A’s brief tobacco intervention model. Refer participants to the workbook for more information to help them select the best-fit model for their organization. Explain that participants will have an opportunity to further experience the 5A’s model. Practice 25 minutes Assign participants to small groups to write out a script demonstrating the 5A’s model using Worksheet 1. Work in small groups to create a script for the 5A’s model. Workbook Refer to the workbook. Ask questions and give feedback. PowerPoint presentation Part IIModule 1-C
Watch the video, ask questions and give feedback.
Workbook, video
Evaluation 20 minutes Ask one group to select two volunteers in that group to role-play the group’s script demonstrating the 5A’s model. Facilitate the role play of the script. Invite participants to make suggestions to fine-tune the model. Role-play their script. Everyone provides feedback and suggestions.
Module 2: The service managers’ role in promoting brief tobacco interventions in primary care Duration Objectives 1 hour and 40 minutes Upon completion of this module, participants will be able to: − describe why primary care service managers are positioned to plan and implement system changes for treating tobacco dependence; − describe the WHO Health System Framework as a tool for strengthening health systems; − support using the WHO Health System Framework as a tool to plan and implement system changes to improve the delivery of brief tobacco interventions in primary care; − describe where and how primary care service managers have influence in each of component of a health system.
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Preparation 15 minutes Remind participants that: • The primary care is an ideal place to identify and treat tobacco users, and it should at least deliver brief tobacco interventions as part of its routine services to help tobacco users quit. • However, in general, less than 50% of primary care providers in the world routinely ask and advise all patients to quit. Primary care providers’ performance in 5A’s delivery in developing countries is likely to be even lower. Ask participants: As a service manager, what would you need in place to ensure that primary Participate in discussion. care providers will be able to routinely identify and help tobacco users? Anticipated response: it is important to have Discuss that it is important to have a well-functioning system in place to support primary care providers to identify and offer treatment, a system in place to and it is the service manager’s responsibility to create such a well- identify and treat tobacco users. functioning system. Presentation 25 minutes Emphasize that the WHO Health System Framework of six building blocks is a good tool for primary care service managers to build a wellfunctioning support system for primary care providers to deliver brief tobacco interventions. Refer participants to the workbook and use a diagram to illustrate the WHO Health System Framework and its building blocks of: – service delivery; – health workforce; – information support; – medical products and technologies; – financing; – leadership and governance. Explain that each of the six building blocks should function well in order for primary care providers to routinely deliver brief tobacco interventions. Refer participants to the workbook and describe: • What does a well-functioning health system look like? • For treating tobacco dependence, what should a well-functioning health system be like? Refer participants to a checklist in the workbook and encourage them that, as primary care service managers, they can influence the change of all six building blocks because of their roles, responsibilities and past experience. The WHO Health System Framework can help them initiate and implement system changes as: – a diagnostic tool to diagnose all system constraints that need to be addressed in order to improve primary care providers’ performance; – a planning tool to plan and implement system changes to overcome the constraints to support primary care providers’ delivery of brief tobacco interventions. Remind participants that, during the rest of the training, they will learn skills and steps to build a personal action plan for initiating new system changes in their own primary care setting to promote the delivery of brief tobacco interventions. Refer to the workbook. Workbook, PowerPoint presentation Part IIModule 2-A
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Practice 30 minutes Explain that participants are now going to practise using the WHO Health System Framework as a diagnostic tool to diagnose in their primary care system the constraints that hinder primary care providers from delivering brief tobacco interventions. Assign participants to small groups to identify in each of the six building blocks: What changes need to be made and what problems need to be addressed in order to improve primary care providers’ performance in delivering brief tobacco interventions? Ask participants to note their results in Worksheet 2. Evaluation 60 minutes Ask each group to share its findings by writing them down on flipchart or whiteboard. Each small group shares ideas. Everyone critiques and gives feedback. Flipchart or whiteboard Work in small groups to identify needed changes for each of the six building blocks. Workbook
Module 3: Integrating brief tobacco interventions into existing infrastructure Duration Objectives 2 hours Upon completion of this module, participants will be able to: − build a roadmap to illustrate how a patient moves through the health-care setting; − identify staff, departments and patient encounters that could be part of the integrated brief tobacco interventions delivery system; − recognize how two primary care settings have integrated tobacco dependence treatment; − identify small system improvements that could make the process more effective or efficient.
Time
Facilitator activity
Participant activity
Audiovisual
Preparation 20 minutes Assign participants to work with the person sitting next to them to draw a diagram (a patient flow) illustrating how a patient moves through a community centre/clinic. Ask volunteers to describe how a patient moves through a primary care setting? Validate responses and prompt participants to include waiting room, examination room, cafeteria, nurse’s station, doctor’s office, laboratory, pharmacy, restroom, and other places. 15 minutes Assign participants to continue working with the person sitting next to them to identify key staff members and their specific roles in helping tobacco users quit: • In your clinic/community centre, who can help tobacco users quit in each patient encounter (at each spot)? • What specific assistance they can provide to tobacco users? Ask participants to add key staff members they have identified to the diagram. Ask volunteers to share key staff members that they have identified and their specific roles. Refer to the workbook and work in pairs to draw a diagram showing how a patient moves through a primary care setting. Workbook, flipchart
Work in pairs to identify Workbook key staff members and their potential role in delivering tobacco dependence treatment based on work experience.
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Preparation 10 minutes Ask participants to review the diagram and brainstorm: If you want to integrate brief tobacco interventions into your primary care services, how many patient encounters could be part of the integrated system? Facilitate brainstorming and capture ideas on the diagram. Remind participants to consider every staff member, including the receptionist, nurses, nursing aides, doctors, pharmacists, laboratory technicians and medical assistants, as well as opportunities in the waiting room, reception area, cafeteria, etc. Presentation 25 minutes Refer participants to case studies. Present: How tobacco dependence treatment is supported in the primary care system. Use the WHO building blocks as an outline to illustrate the two examples. Refer participants to the workbook and explain that WHO building blocks can be a useful tool to identify action steps for integrating brief tobacco interventions into their primary care systems. Practice 30 minutes Refer participants to Worksheet 3 in the workbook. Divide participants into small groups to identify small system improvements that could facilitate the delivery of brief tobacco interventions or make the process more effective or efficient, taking into consideration the existing primary care system infrastructure. Evaluation 20 minutes Groups debrief by sharing their findings. Write down ideas on flipchart or whiteboard. Invite participants to fine-tune and/or add to ideas. Each small group shares ideas. Everyone critiques and gives feedback. Flipchart or whiteboard Work in small groups to review each building block, and then identify small system improvements. Refer to the workbook. Workbook, case studies, PowerPoint presentation Part IIModule 3-A Brainstorm possible patient encounters that could be part of the integrated treatment system. Conclude: there are many opportunities during a patient visit to initiate or deliver brief tobacco interventions. Workbook, flipchart
Module 4: Getting support from stakeholders Duration Objectives 2 hours 15 minutes Upon completion of this module, participants will be able to: − identify and solicit support from stakeholders, policy-makers, and champions in organizations; − anticipate stakeholder needs and refute objections (concerns about conflicting priorities, costs); − identify organizational policies and regulations that support the routine identification of tobacco users and provision of brief tobacco interventions (including smoke-free policy in the organization).
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Preparation 20 minutes Explain that, to ensure that a system change is successful we need: − support from relevant stakeholders; − champions; − supportive organizational policies, regulations and incentives. Tell participants that this module will cover how to obtain support from relevant stakeholders, how to find champions, and how to identify supportive organizational policies. The incentives will be discussed in Module 6 Ask participants: • Who are the stakeholders that you need to involve in making system changes to improve the delivery of brief tobacco interventions? • Who are champions? Write responses on a flipchart or whiteboard. Summarize that: • The potential stakeholders are individuals or groups who can affect or be affected by your project. • Champions are a stakeholder group who are deeply interested in your project and are supportive of your project. Presentation 20 minutes Present four steps of engaging with stakeholders: 1. Identify your stakeholders. 2. Prioritize your stakeholders. 3. Understand your key stakeholders. 4. Determine appropriate strategies and actions to approach your key stakeholders. Explain that: • Step 1 is for participants to brainstorm in each of the six building blocks: − Who has influence or power over your system changes? − Who has an interest in your system changes? − Who are affected by your system changes? • Step 2 is for participants to decide who the key stakeholders are. This can be achieved through mapping out stakeholders’ positions on an influence/interest grid. • Step 3 will allow participants to know more about their key stakeholders in terms of: − How would this stakeholder define a positive outcome for a tobacco dependence treatment programme? − What can this stakeholder gain from an improved system for tobacco dependence treatment? − What are the barriers or challenges that would limit this stakeholder’s participation in this programme? − What would be an incentive for this stakeholder to participate in this programme? • Step 4 is for participants to decide appropriate strategies and actions they have to take with different stakeholders and how best to communicate with them, based on stakeholders’ positions on the influence/interest grid. Refer to the workbook. Workbook, PowerPoint presentation Part IIModule 4-B Participate in discussions. Flipchart or whiteboard, PowerPoint presentation Part IIModule 4-A
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Presentation 10 minutes State that, when approaching stakeholders, one issue stakeholders may bring up is cost. They may also raise other disease priorities (HIV, tuberculosis, diabetes, cardiovascular disease). The participants need to be well prepared to explain how tobacco dependence treatment is justified. Refer participants to the workbook and use PowerPoint slides to illustrate the cost-effectiveness of brief and intensive tobacco use treatments, as well as why treatment of tobacco dependence should be a priority for health systems. 15 minutes Ask participants to brainstorm: − how champions can effect system changes; − how to identify champions; − the qualities of a successful champion. Write responses on a flipchart or whiteboard. Refer participants to the workbook and present suggested answers to those questions. Emphasize that the WHO Health System Framework can be a useful tool to identify champions. 10 minutes Explain that implementing and institutionalizing a system change for tobacco dependence treatment is dependent on supportive organizational policies and regulations (e.g. smoke-free policy in primary care facilities). If these do not exist, we should get stakeholders’ support to develop new policies/regulations. Participate in the discussion, ask questions and give feedback. Workbook Participate in the discussion, ask questions and give feedback. Workbook, flipchart or whiteboard, PowerPoint presentation Part IIModule 4-D Refer to the workbook. Workbook, PowerPoint presentation Part IIModule 4-C
Practice 30 minutes Assign participants to work in small groups to: − identify stakeholders who may influence changes in each of the six building blocks (each group works one block); − map out the stakeholders on the influence/interest grid; − select one key stakeholder and analyse this stakeholder’s perspective regarding incentives and challenges/barriers to supporting changes; − write a message to gain the stakeholder’s support using Worksheet 5. Review worksheets. Work in small groups to select one stakeholder and analyse this stakeholder’s perspective regarding incentives and barriers. Then write a message to gain the stakeholder’s support. Workbook
Evaluation 30 minutes Ask each group to present the stakeholder message. Everyone helps critique and adds to the message. Conclude that this exercise is the beginning of developing a communication plan to engage with stakeholders, which typically includes the following components: − an objective (why to communicate); − a message to win support (what to communicate); − a strategy (how to communicate); − a start time (when to communicate); − a spokesperson (who to communicate). A good stakeholder communication plan is essential to the success of any new system change design and implementation. Everyone helps critique and adds to solutions.
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Facilitators’ guide
Module 5: Community participation Duration Objectives 1 hour 50 minutes Upon completion of this module participants will be able to: − distinguish consumer from community; − identify stakeholders, champions, and partners in the community; − identify resources available in the community; − identify opportunities to work with community partners.
Time
Facilitator activity
Participant activity
Audiovisual
Preparation 10 minutes State that: • Community participation is a core principle underpinning the development of primary care. • A successful programme depends on community involvement. • Communities can play a variety of roles in developing and providing services to treat tobacco dependence in primary care. Assign participants to pair up with the person sitting next to them and take the next few minutes to make a list of: − consumers of their primary care centre; − members of the community served by their centre. 10 minutes Ask volunteers to share their list of consumers and community members. Share the list of consumers and Write responses on a flipchart page or whiteboard. Build a consumercommunity members. community continuum, writing down patients at the top of the list and taxpayers and government agencies at the other end. Discuss with participants and prompt them to conclude that: • Primary care organizations should be responsible to the whole community, and not only to consumers. • Consumers are part of the whole community and the priority of community involvement for promoting tobacco dependence treatment must be on key community organizations (such as the thematic NGOs, government organizations). Presentation 30 minutes Explain that the goals of community participation in strengthening health systems to deliver brief tobacco interventions in primary care are to see: − tobacco dependence treatment high on the agenda of the community; − increasing demand from tobacco users through public education; − utilization of community resources in supporting tobacco dependence treatment. Ask: How can primary care service managers meet these goals? Prompt that this was partly discussed in Module 4. Refer participants to the workbook and summarize that primary care service managers will need to: − identify, assess and promote active involvement of key community partners (leadership groups/organizations); − identify and promote utilization of community resources. Use PowerPoint slides to present the knowledge, skills and tools for: − identifying community leadership groups/organizations for achieving each of the three goals; − assessing the level of community involvement; − promoting community involvement to meet the goals. Refer to the workbook. Participate in the discussion. Workbook, PowerPoint presentation Part IIModule 5-B Workbook, flipchart or whiteboard, PowerPoint presentation Part IIModule 5-A Participants work in pairs to define consumers and the larger community members served by their organization. Workbook
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Practice 30 minutes Refer participants to Worksheet 6. Assign participants to work in small groups to: − identify community leadership groups/organizations for achieving the above-mentioned three goals; − assess the current level of community involvement with the identified community leadership groups/organizations; − identify the capacities/resources of the community leadership groups/organizations in achieving each of the three goals; − assess the community leadership groups/organizations’ attitudes towards collaboration and participation in a tobacco dependence treatment programme; − brainstorm ways of encouraging and soliciting community participation. (financial support, donated labour, in-kind material support, monitoring; professional experience, other.) Evaluation 30 minutes Ask participants to share their results. Share the results. Work in small groups Workbook to identify and assess the current level of involvement, identify resources and strategies to promote community involvement using Worksheet 6.
Prompt discussion by reviewing the community leadership groups, community involvement strategies, and available resources and capacities. Everyone adds to the discussion and gives Point out that they actually have developed a community participation feedback. plan by completing Worksheet 6.
Module 6: Sustaining a system change: feedback, motivations and incentives Duration Objectives 1 hour 50 minutes Upon completion of this module participants will be able to: − define workplace motivation and incentives; − describe effective incentive systems; − use the WHO Health System Framework to identify effective incentives for primary care providers to routinely deliver brief tobacco interventions; − build an incentive plan for their primary care organization.
Time
Facilitator activity
Participant activity
Audiovisual
Preparation 10 minutes Introduce the topic of motivation and incentives by asking participants to brainstorm: Why are incentives an important part of implementing a system change for treating tobacco dependence? Anticipated response: providers have heavy workloads and conflicting priorities. Incentives that are important to them increase the likelihood that they will perform the intervention. Workbook
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Preparation 10 minutes Assign the participants to three small groups. Each group will have 10 minutes to generate a list of workplace incentives it finds effective. Challenge the groups to compile a long list of quality ideas and tell them that the group with the longest list will win a prize. Give different levels of support to each group to simulate the impact of incentives, training and feedback on motivation. Group 1: receives no support to complete the task. Group 2: receives information about criteria for quality incentives to help compile its list. Group 3: receives information about criteria for quality incentives to help compile its list; and halfway through the exercise, the facilitator provides feedback about the number of suggestions on the other groups’ lists, as well as some feedback about the quality of the suggestions. Circulate during the exercise and chat with each group. During the chat, provide feedback to group 3. 10 minutes Debrief the exercise. Explain that the exercise was an experiment. Review the number of suggestions that were generated. Use criteria to discuss the quality of ideas generated. Ask participants to share their experience and discuss how motivation and performance were impacted by incentives, training and feedback. Presentation 25 minutes Refer participants to the workbook. Present: − the definition and components of workplace motivation; − the definition of incentives; − how providing incentives is the most reliable method to improve workplace motivation; − the characteristics of effective incentive systems. Use case studies to demonstrate low-cost methods for providing incentives such as: reward systems, posting job performance and budget reallocations. Explain that participants can use the building blocks to identify incentives to reward success, considering each component of the system. Practice 30 minutes Assign small groups to brainstorm a list of incentives that relate to each of the six building blocks to motivate primary care providers to perform brief tobacco interventions routinely. Consider how you can leverage the perceived importance of the task, self-efficacy and expectancy. The group synthesizes the list and recommends incentives that could work in their system. Evaluation 25 minutes Ask participants to share their list of effective incentives. Everyone critiques the list and fine-tunes the incentive systems. Validate and add to the list. 16
Work in small groups to generate a list of workplace incentives they find effective. Anticipated response: each group generates a list of incentives. Anticipate that the groups that receive feedback and experience competition are more invested in the activity and will generate a longer list.
Workbook
Participants conclude that incentives can improve motivation, and that training and feedback can improve satisfaction and performance.
Workbook
Refer to the workbook.
Workbook, PowerPoint presentation Part IIModule 6-A
Work in small groups and identify a list of incentives.
Workbook
Workbook
Strengthening health systems for treating tobacco dependence in primary care / Part II
Facilitators’ guide
Module 7: Your action plan to implement a system change Duration Objectives 3 hours 30 minutes Upon completion of this module participants will be able to: − describe the importance of planning in initiating successful system changes; − describe the steps of creating an action plan; − develop an action plan and deliver a presentation that summarizes their action plan; − present a synthesis of the knowledge and skills gained during training to demonstrate new insight about the process of strengthening health systems for delivery of brief tobacco interventions using the WHO building blocks. Facilitator activity Participant activity Audiovisual
Time
Preparation 20 minutes Use a planning exercise named “Paper Tower” for participants to experience the importance of planning in initiating successful changes. 1. Divide participants into small groups (4 to 8 persons per group). 2. Give each group five sheets of A4 paper and five centimetres of tape. 3. Present the challenge (pre-prepare this statement on a flipchart): • “You have been given five sheets of A4 paper and five centimetres of tape. The task is to build the tallest tower in five minutes using no other materials. The time starts NOW.” After the five minutes and a review of the structures, prompt a discussion related to planning: • Who planned their structure? • How did they ensure that all group members knew the plan? • Who ran out of time? • What could be done differently next time? Reinforce comments related to the role of planning. Tell participants that in this module they will learn and practise how to make a solid action plan for implementing a system change to improve the delivery of brief tobacco interventions in primary care. Presentation 40 minutes Ask participants to brainstorm: • What is an action plan? • What does an action plan look like? Use PowerPoint slides to explain the definition of an action plan and the key aspects of an action plan. Use PowerPoint slides and examples to explain the five steps of creating an action plan to change each of the six health system building blocks: 1. Define the issue or problem to be addressed (it has been completed in Module 2). 2. Identify opportunities and challenges to bring about the desired changes. 3. Set objectives. 4. Construct action steps (list of actions, timelines, responsible persons). 5. Format the action plan. Participate in the discussion and contribute ideas. Workbook, PowerPoint presentation Part IIModule 7-A Work in small groups to build a paper tower in five minutes. Flipchart, A4 paper and tape
Participate in the discussion and give feedback and comments.
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Facilitators’ guide
Time
Facilitator activity
Participant activity
Audiovisual
Practice 60 minutes Refer participants to Worksheet 2. Assign small groups to: 1. Select one needed change in any of the six building blocks that could improve the delivery of brief tobacco interventions. 2. Make an action plan for implementing the selected change. 3. Prepare an 8−10-minute presentation to present the action plan. The group presentation should include: − a description of the issue or problem that needs to be addressed in your primary care setting; − challenges and opportunities for bringing about the desired change; − your SMART objective; − a list of action steps; − monitoring and evaluation; − who stakeholders and/or champions are; − how the community can be involved. Provide assistance for groups that want to create visuals. Evaluation 60 minutes Ask each group to deliver its presentation. Everyone listens and Conclude that action plans are pointless unless you make every effort to gives feedback. implement them. So the next steps are implementation and monitoring and evaluation (M&E). Closing remarks, evaluation Workbook, PowerPoint presentation Part IIModule 7-B Work in small groups to Workbook, create action plans and flipchart and prepare presentations. extra marking pens
Closure 30 minutes
18
PARTICIPANTS’ WORKBOOK Module 1: Setting the stage for increasing access to tobacco dependence treatment in primary care Objectives Upon completion of this module participants will be able to: − recognize the burden of tobacco use and the potential of tobacco cessation to save lives; − articulate the rationale for identifying and offering help to tobacco users in a primary care setting; − describe what tobacco dependence treatment should be routinely offered in primary care; − describe at least three brief tobacco intervention models; − role-play a brief tobacco intervention model. Agenda 1. The burden of tobacco use and the potential of tobacco cessation to save lives (20 minutes). 2. The rationale for promoting access to treatment of tobacco dependence in primary care settings (10 minutes). 3. Existing effective tobacco cessation services in primary care settings (10 minutes). 4. Overview of brief tobacco interventions (25 minutes). 5. Creating a script for the 5A’s model (25 minutes). 6. Role playing the 5A’s model (20 minutes). Preparation 1. The burden of tobacco use and the potential of tobacco cessation to save lives (20 minutes) Brainstorming What are the problems caused by tobacco use in your community?
1.1 Health burden of tobacco use Tobacco kills up to half of its users. As a leading cause of death and illness, tobacco kills more than 5 million people who directly use tobacco (both smoking and smokeless). Second-hand smoke also kills. Second-hand smoke causes more than 600 000 premature deaths worldwide each year. 1.2 Economic burden of tobacco use 1.2.1 Costs to society Tobacco companies argue that smoking has positive economic benefits. They claim that tobacco control programmes will lead to a loss of tax revenue, cause unemployment and create financial hardship because people will live longer. Despite industry claims, the cost of tobacco use outweighs the benefits. • The estimated annual cost of tobacco use to societies globally is US$ 500 billion, which exceeds the total annual expenditure on health in all low-and middle-income countries. • Every country suffers huge economic losses due to tobacco use (see some examples in Table 1). • Tobacco’s total economic costs reduce national wealth in terms of gross domestic product (GDP) by as much as 3.6%. 19
Strengthening health systems for treating tobacco dependence in primary care / Part II
Participants’ workbook
Table 1. Cost* attributable to tobacco use (US$) (2007 or latest available data) USA Japan Germany Canada France China Egypt 167.00 billion 62.39 billion 23.75 billion 17.00 billion 15.30 billion 5.00 billion 1.25 billion
* Direct health care costs plus indirect costs, including productivity losses, absenteeism and other socioeconomic costs.
1.2.2 Costs to families and individuals Another significant cost related to tobacco use is the suffering of families and individuals because of diminished quality of life, death and financial burden. “Smoking makes the poor poorer; it takes away not just their health but wealth” (Dr. Bill O’Neill, Secretary of the British Medical Association Scotland, 2004). Tobacco products are expensive. For example, the price of 20 Marlboro cigarettes could buy − a dozen eggs in Panama; − one kilogram of fish in France; − four pairs of cotton socks in China; − 6 kilograms of rice in Bangladesh. Tobacco use is costly with 5−15% of a tobacco user’s disposable income being spent on tobacco. The poor people often have to cut their expenditure on food and education. 1.3 The potential of tobacco cessation to save lives Supporting current tobacco users to quit synergistically with the implementation of other tobacco control measures contained in the WHO FCTC can bring about immediate changes in prevalence rates and tobacco-related death and disease. This is because the short- to medium-term tobacco-related death and disease are due to its current users. It was estimated that if adult tobacco consumption were to decrease by 50% by the year 2020, about one third of the global tobacco-related deaths could be avoided by the year 2050 (see Figure 1). Therefore, countries concerned with health gains in the short- to medium-term should consider supporting tobacco users to quit as part of any comprehensive tobacco control programme, as reflected in the WHO FCTC.
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Participants’ workbook
Figure 1. Estimated cumulative tobacco deaths 1950–2050 with different intervention strategies
520 500 500 Baseline If proportion of young adults taking up smoking halves by 2020 If adults consumption halves by 2020 220 200 190 100
400 Tobacco deaths (millions) 340 300
70
0 1950
2000
Year
2025
2050
Curbing the epidemic: governments and the economics of tobacco control (Development in Practice Series). Washington, DC, The World Bank, 1999.
Presentation 2. The rationale for promoting access to treatment of tobacco dependence in primary care settings (10 minutes) Although treatment of tobacco dependence should be made available in a country’s whole health system at all levels of service delivery – including primary, secondary and tertiary health-care settings – primary care settings should be the main focus. Below are the rationales for promoting access to treatment of tobacco dependence in primary care settings: • The public health impact of an intervention/service depends on effectiveness, reach and delivery cost. The primary care setting is a less costly setting for reaching the majority of tobacco users in many countries. Therefore, brief tobacco interventions could have a significant public health impact if primary care providers can routinely provide brief tobacco interventions to tobacco users.
Reach • The primary care staff have long and close contact with the community and are well accepted by local people. • The primary care is the primary source of health care and can reach the majority of the population in many countries. For instance: − In Brazil, 70% of the population receives free health care from the public system. − In Cuba, the national health care programme addresses the needs of over 95% of the population. − In Fiji, 70−80% of the population has access to health services. − In Thailand, the universal coverage scheme provides health care for most of the country’s 64 million people. • Primary care programmes appear to reach the poor far better than other types of health programmes do, and the poor are the ones who smoke the most (see Figure 2).
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Participants’ workbook
Figure 2. Prevalence of tobacco use within countries and between countries at different levels of development
Q1 28.00 26.00 24.00 22.00 20.00 18.00 16.00 14.00 12.00 10.00 Low income Source: World Health Survey, 2006.
Q2
Q3
Q4
Q5
Note: Q1-Q5: Lowest-highest income groups.
%
Lower-middle income
Upper-middle income
High income
Delivery cost • Resources for health will always be limited. Primary care approach is a route to achieving maximum possible affordable coverage of effective tobacco cessation services with available resources. For instance: − The primary care setting is less costly as the primary care approach emphasizes providing as much care as possible at the first point of contact through integrated service delivery models. − Various opportunities and entry points exist for integrating identification and treatment of tobacco users in primary care services (e.g. DOTS strategy, programmes dealing with cardiovascular disease, chronic obstructive pulmonary disease, diabetes, maternal and child health). 3. Existing effective tobacco cessation services in primary care settings (10 minutes) Brainstorming Which tobacco dependence treatments should be routinely offered in primary care?
Various effective tobacco dependence treatment methods exist: Brief counselling from health professionals Group counselling in a clinic or community Telephone quitline Self-help materials Pharmacological treatments: nicotine replacement therapy (NRT), bupropion, and varenicline Quit and Win competitions Others: .
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Participants’ workbook
The guidelines for implementation of Article 14 of the WHO FCTC recommend that: − all Parties should aim to provide the fullest complement of interventions for tobacco cessation and treatment of tobacco dependence; − if they cannot provide comprehensive treatment simultaneously, Parties should use a stepwise approach to developing tobacco dependence treatment and start with providing tobacco users with brief advice. In line with the Article 14 guidelines, WHO recommends that countries should at least deliver brief tobacco interventions as part of routine services in primary care. This training is designed to help primary care service managers strengthen their health systems to improve the delivery of brief tobacco interventions by primary care providers – in other words, to help primary care service managers integrate brief tobacco interventions into their primary care services. 4. Overview of brief tobacco interventions (25 minutes) 4.1 Brief tobacco intervention models While more intensive or longer-lasting treatments are more likely to help patients stay smoke-free, Primary care providers can help patients successfully quit tobacco use by offering interventions as short as three minutes. There are several structured models available to help them deliver these brief tobacco interventions. Here are some examples: 5A’s: Ask, Advise, Assess, Assist, Arrange (for patients who are ready to quit). Ask − systematically identify all tobacco users at every visit. Advise − advise all tobacco users that they need to quit. Assess − determine readiness to make a quit attempt. Assist − assist the patient with a quit plan or provide information on specialist support. Arrange − schedule follow-up contacts or a referral to specialist support. 5R’s: Relevance, Risks, Rewards, Roadblocks, Repetition (to increase motivation of patients who are not ready to quit). The 5R’s are designed to motivate smokers who are unwilling to quit at this time. Smokers may be unwilling to quit due to misinformation, concern about the effects of quitting, or demoralization because of previous unsuccessful quit attempts. Therefore, after asking about tobacco use, advising the smoker to quit, and assessing the willingness of the smoker to quit, it is important to provide the 5R’s motivational intervention. AAR: Ask, Advise, Refer. This is an alternative protocol that takes less training and can be easily implemented. The health-care provider asks or identifies smoking patients, advises them to quit (thus doubling the chances that they will try), and refers them to a quitline or provides other resources.
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Participants’ workbook
AAA: Ask, Advise, Act. Ask about smoking. Advise tobacco users to quit. In a clear, strong, and personalized manner, urge every smoker to quit. Act on the patient’s response. Assist the smoker to: Set a quit date, ideally within two weeks. Tell friends, family and coworkers of plans to quit, and ask for support. Anticipate challenges, particularly during the critical first few weeks, including nicotine withdrawal. Remove cigarettes from home, car and workplace and avoid smoking in these places. Make their home smoke-free. Give advice on successful quitting: total abstinence is essential (not even a single puff); avoid drinking alcohol to prevent relapse, etc. ABC: Ask, Brief advice, Cessation support. Ask about smoking status. Give Brief advice to stop smoking to all people who smoke. Provide evidence-based Cessation support for those who express a desire to stop. For more information about the ABC model, please review the New Zealand Smoking Cessation Guidelines. You can also take an online course about tobacco cessation and the ABC model at https://smokingcessationabc.org.nz. 4.2 Demonstration of brief tobacco interventions Watch a video demonstrating that brief tobacco interventions (5A’s) can be done within three minutes. Table 2 gives another example of using the 5A’s model to deliver brief tobacco interventions. Table 2. 5A’s Model demonstration Primary care provider Patient Ask Primary care provider Patient Advise Primary care provider Patient Assess Primary care provider Patient Good morning Ms Fleming. What brings you in today? My son’s asthma is bad again and I think he might have an ear infection. I’ll examine him and see what can be done to help him feel better. Before I do that I need to check something out with you. Are you still smoking? Yes I am. I know I should quit, but I’m just not ready to do that. I hear that you’re not ready to quit, but I need to tell you that your son’s health problems are related to his exposure to smoke and I advise you to quit. Oh, I didn’t know that. Maybe I should think about quitting. Great. Are you ready to quit in the next 30 days? Yes, but I just don’t know where to start.
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Participants’ workbook
Assist
Primary care provider
OK. You could start by setting up a quit date, and telling your family and friends that you plan to quit and ask them to support you. Can you pick a specific day within the next one to two weeks as your quit date? OK. Next Saturday is my birthday. I will quit on that day. That is great. You can prepare for the quit day by thinking about potential challenges and possible solutions. You can plan ahead by finding healthy oral substitutes like carrots and sugar-free candy, finding things to do with your hands, and learning deep breathing and other relaxation techniques. I will follow your suggestions. Thank you. I will call you one week after your quit date to see if you need any help. Now let’s have a look at your son. OK, thank you doctor.
Patient Primary care provider
Patient Arrange Primary care provider Patient
To maximize effectiveness, you need to select a best-fit model to deliver brief tobacco interventions for your primary care organization on the basis of the availability of existing intensive tobacco dependence treatment services in the community, existing infrastructure and the way your organization operates. Practice 5. Creating a script for the 5A’s model (25 minutes) Work in small groups and review each step of the 5A’s model. Your group will be assigned to develop a script for delivering the 5A’s model using the following scenario: You are seeing Mr Jack for the third time in six months for bronchitis. You learn that Mr Jack smokes cigarettes. How will you apply the 5A’s during your visit with this patient? Use this checklist to develop your script: Ask your patient about his/her tobacco use. Advise your patient to quit, using a clear, strong and personalized message. Assess your patient’s readiness to make a quit attempt. Assist your patient. • If your patient is willing to quit within the next 30 days, assist your patient to: Set a quit date, ideally within two weeks. Tell friends, family and coworkers of plans to quit, and ask for support. Anticipate challenges, particularly during the critical first few weeks, including nicotine withdrawal. Remove cigarettes from home, car and workplace and avoid smoking in these places. Make his/her home smoke-free. • If your patient is not willing to quit, assist your patient by providing a brief motivational message exploring relevant Risks, Rewards and Roadblocks and by offering educational materials that describe the benefits of quitting and the consequences of tobacco use. Arrange for follow-up whenever possible. For smokers who are unwilling to quit, let them know that you are available whenever they are ready to quit. Inform them that you will continue to ask about their tobacco use. Please note your script in Worksheet 1 and be prepared to role-play your script in a group role play. Evaluation 6. Role playing the 5A’s model (20 minutes) Please volunteer to role-play the script of the 5A’s model that your group has developed. If you are not role-playing, please observe carefully and help provide your comments and suggestions to fine-tune the model.
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Participants’ workbook
Worksheet 1. Primary care provider
Jack
Ask
Primary care provider
Jack
Advise
Primary care provider
Jack
Assess
Primary care provider
Jack
Assist
Primary care provider
Jack
Arrange
Primary care provider
Jack
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Participants’ workbook
Module 2: The service managers’ role in promoting brief tobacco interventions in primary care Objectives Upon completion of this module participants will be able to: − describe why primary care service managers are positioned to plan and implement system changes for treating tobacco dependence; − describe the WHO Health System Framework as a tool for strengthening health systems; − support use of the WHO conceptual framework as a tool to plan and implement system changes to improve the delivery of brief tobacco interventions; − describe where and how primary care service managers have influence in each of the building blocks. Agenda 1. What a primary care service manager needs to put in place to support primary care providers to identify and treat tobacco users (15 minutes). 2. The WHO Health System Framework: a tool for strengthening health systems (15 minutes). 3. What systems changes can primary care service managers make to improve the delivery of brief tobacco interventions (10 minutes). 4. Using the WHO Health System Framework to diagnose constraints in the primary care system (30 minutes). 5. Evaluation (30 minutes). Preparation 1. What a primary care service manager needs to put in place to support primary care providers to identify and treat tobacco users (15 minutes) While the primary care setting is an ideal place to identify and treat tobacco users, in general less than 50% of primary care providers routinely ask and advise all patients to quit. • In developed countries, a multicentre study across 12 European countries found that, overall, only 36% of health professionals reported always advising patients to quit smoking. • In developing countries, primary care providers’ performance in 5A’s delivery is likely to be even lower. For example, a study has documented that only 12.9% of the patients were asked for tobacco use and 11.9% of tobacco users reported being advised against tobacco use during the current visit in South African primary care. Brainstorming As a service manager, what would you need in place to ensure that primary care providers will be able to identify and treat tobacco users?
Only a well-functioning system ensures that primary care providers routinely identify and provide brief tobacco interventions to all tobacco users at every visit. It is primary care service managers’ responsibility to have such a supportive system in place to support primary care providers.
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Participants’ workbook
Presentation 2. The WHO Health System Framework: a tool for strengthening health systems (15 minutes) 2.1 WHO Health System Framework The WHO Health System Framework (six building blocks) (Figure 3) can be a good tool for primary care service managers to use to build a well-functioning health system to support primary care providers to routinely deliver brief tobacco interventions. This framework illustrates the basic functions all health systems have to carry out and defines a set of six essential building blocks to help people understand how to strengthen health system. The building blocks are: − service delivery; − health workforce; − information support; − medical products and technologies; − financing; − leadership and governance. Figure 3. The WHO Health System Framework
System building blocks Service Delivery Health Workforce Information Medical Products, Vaccines & Technologies Financing Leadership / Governance Quality Safety Access Coverage
Overall Goals / Outcomes
Improved Health (level and equity) Responsiveness Social and Financial Risk Protection Improved Efficiency
The WHO Health System Framework shows practical ways to strengthen health systems by using six operational “building blocks” to: − locate, describe and classify health system constraints; − identify where and why interventions are needed; − predict the effects of a health system strengthening intervention on its results. 2.2 What does a well-functioning health system look like? In order for primary care providers to routinely deliver brief tobacco interventions, all six building blocks should function well. Below are the main features of a well-functioning health system: Service delivery Delivering effective, safe, high-quality personal and public health interventions to those who need them, with minimum waste of resources. Health workforce There are sufficient numbers and mix of staff, fairly distributed. They are competent, responsive and productive.
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Information support Ensuring the production, analysis, dissemination and use of reliable and timely information on tobacco use and health-systems performance. Medical products and technologies Ensuring equitable access to essential medical products and technologies, and their scientifically sound and cost-effective use. Financing Raising adequate funds for health in ways that ensure people can use services and are protected from financial hardship or impoverishment associated with having to pay for them. Leadership/governance Ensuring that strategic-policy frameworks exist and are combined with effective oversight, coalition-building, provision of appropriate regulations and incentives, attention to system design, and accountability. As for tobacco dependence treatment, a well-functioning health system is one that allows any tobacco users, wherever they live and whatever their social and economic circumstances, to access appropriate, good quality brief tobacco interventions as part of primary care services, with referral to existing intensive treatments (quitline, specialist treatment) when needed, without the risk of financial hardship. 3. What system changes can primary care service managers make to improve the delivery of brief tobacco interventions (10 minutes) Table 3 is a checklist of effective systems-level changes (organizational policies and practices) that you can make to improve the function of all six building blocks in order to improve the delivery of brief tobacco interventions. Emerging evidence shows that systems-level interventions can enhance the delivery of effective tobacco cessation treatment to patients by health-care professionals and can increase patient quit rates, quit attempts and use of treatment. • Introduction of electronic health records (EHR) can, at least in the short term, increase documentation of tobacco status and referral to cessation counselling; • Training health-care professionals to provide smoking cessation interventions had a measurable effect on professional performance. The effects of training on performance of smoking cessation interventions increased if prompts and reminders were used. • Financial benefits extended to health-care providers can significantly increase the use of behavioural interventions for smoking cessation. • Full financial interventions directed at smokers (covering all the costs of treatment), when compared to no financial interventions, could increase the proportion quitting, quit attempts and utilization of pharmacotherapy by smokers.
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Strengthening health systems for treating tobacco dependence in primary care / Part II
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Table 3. A checklist of systems-level changes to promote brief tobacco interventions in primary care settings Service delivery • Strategies to improve integrated delivery of brief tobacco interventions: − Brief tobacco interventions integrated into existing health programmes (e.g. tuberculosis, cardiovascular diseases, diabetes, cancer, maternal and child health programmes in primary care). • Models to implement brief tobacco interventions (e.g. 5A’s, 5R’s, AAA, AAR, ABC). • Referral to existing effective tobacco dependence treatments in primary care settings: − cessation clinics (face-to-face individual or group-intensive counselling as well as pharmacotherapy where possible); − telephone quitlines; − community self-help cessation programme. • Equity: − help every tobacco user; − help every passive smoker. • Help every primary care provider recognize that it is his/her job responsibility to identify and provide brief tobacco interventions to every tobacco user who presents to a primary care facility. • Training on brief tobacco interventions: − in-service training; − pre-service training. • Help health professionals quit tobacco use and serve as non-tobacco use role models. • Ensure the availability and distribution of an appropriate number of tobacco dependence treatment specialists. • A tobacco-use identification system: − tobacco-use status stickers on all patient charts (including treatment cards for tuberculosis, HIV/AIDS, diabetes, chronic obstructive pulmonary disease, asthma, cancer, etc.); − a vital sign stamp (expanding the vital signs to include tobacco use); − a field in the computer information system where one can enter tobacco use status, if appropriate. • A provider reminder system: − chart sticker or stamp; − indicate tobacco use status using computer reminder systems, if appropriate. • Recognize the key role and responsibility of primary care service managers in promoting brief tobacco interventions. • Provision of appropriate regulations and incentives to support integrated delivery of brief tobacco interventions: − develop and disseminate clinical guidelines and service standards; − reimburse providers for their service delivery; − include the delivery of brief tobacco interventions in staff performance evaluations; − provide feedback to providers about their practices. • Buy-in from professional bodies to include tobacco dependence treatment in their examinations or registration requirements. • Ensure that all sections of the health-care facility are entirely smoke-free. • Attention to system-design: − develop a policy and mechanism for integrated service delivery in primary care where possible; − ensure a fit between strategy and structure and reducing duplication and fragmentation. • Collaboration and coalition-building: − engage with communities, NGOs and the private sector; − advocate and link to population-level tobacco control interventions in the community. • • • • Promote the availability of NRT and other effective smoking cessation medicines. Protocol/toolkit/guide to aid health professionals in providing brief tobacco interventions. Develop information materials (self-help materials, poster and brochure). Promote appropriate use of motivational tools: − risk charts (facilitate physician-patient discussion about disease risk); − visual motivational tools (e.g. carbon monoxide monitor). Health insurance covers tobacco dependence treatment. Resource mobilization raising additional funds for tobacco dependence treatment (e.g. taxes on tobacco). Improving efficiency of resources. Financial incentives for efficient integrated service provision.
Health workforce
Information system
Governance and leadership
Medical products and technologies
Financing
• • • •
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Strengthening health systems for treating tobacco dependence in primary care / Part II
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The WHO Health System Framework can help primary care service managers initiate and implement new systems changes, such as: − a diagnostic tool to diagnose all system problems/constraints in each of the six building blocks that need to be addressed in order to improve primary care providers’ performance in delivering brief tobacco interventions; − a planning tool to plan and implement system changes to support primary care providers to routinely treat tobacco users. Practice 4. Using the WHO Health System Framework to diagnose constraints in the primary care system (30 minutes) You are now going to practise using the WHO Health System Framework as a diagnostic tool to diagnose the constraints in your primary care system that hinder primary care providers from delivering brief tobacco interventions. Please draw on your previous experience and work with your small group to identify in each of the six building blocks: • What changes need to be made/what problems need to be addressed in order to improve the delivery of brief tobacco interventions? Please note your results in Worksheet 2. 5. Evaluation (30 minutes) Each group should write its findings on flipchart paper or whiteboard. Please help provide your comments on other groups’ results.
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Worksheet 2.
Building blocks Service delivery
Changes needed (problems need to be addressed)
Health workforce
Information support
Medical products and technologie
Financing
Leadership and governance
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Strengthening health systems for treating tobacco dependence in primary care / Part II
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Module 3: Integrating brief tobacco interventions into existing infrastructure Objectives Upon completion of this module participants will be able to: − build a roadmap to illustrate how a patient moves through the health-care setting; − identify staff, departments and patient encounters that could be part of the integrated brief tobacco interventions delivery system; − recognize how two primary care settings integrated tobacco dependence treatment; − identify small system improvements that could make the process more effective or efficient. Agenda 1. Patient flow at primary care facilities (20 minutes). 2. Identifying patient encounters that could be part of the integrated treatment system (25 minutes). 3. Case studies of integrating tobacco dependence treatment into primary care systems (25 minutes). 4. Identifying small system improvements to facilitate the delivery of brief tobacco interventions in primary care settings (30 minutes). 5. Evaluation (20 minutes). Preparation 1. Patient flow at primary care facilities (20 minutes) Work with the person sitting next to you and draw a diagram of how a patient moves through your primary care setting. 2. Identifying patient encounters that could be part of the integrated treatment system (25 minutes) 2.1 Identifying key staff members and their potential role in helping tobacco users Continue working with the person sitting next to you to discuss in each of the patient encounters in the above diagram: • Who can help tobacco users quit? • What specific assistance they can provide to tobacco users?
Please add them to the corresponding patient encounters in your diagram.
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Strengthening health systems for treating tobacco dependence in primary care / Part II
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Map how a typical patient moves through your primary care setting
Patient enters the centre:
Patient leaves the centre.
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2.2 Patient encounters and the integrated system for delivering brief tobacco interventions Based on the exercise, please list how many patient encounters could be part of the integrated system if you want to integrate brief tobacco interventions into your primary care services?
Please note that: there are many opportunities during a patient visit to initiate or deliver brief tobacco interventions (such as the waiting room, the receptionist, cafeteria, etc.). Presentation 3. Case studies of integrating tobacco dependence treatment into primary care systems (25 minutes) You can use the WHO building blocks as a tool to plan action steps to integrate brief tobacco interventions into your primary care system. The following two case studies have illustrated how tobacco dependence treatment has been successfully integrated into primary care systems using the WHO six building blocks. Case study 1: Group Health cooperative Group Health is a nonprofit health plan in the USA that serves over half a million people. It is an integrated practice plan and has its own medical staff. In 1991 Group Health consumers had a smoking prevalence of about 25% and Group Health had a goal of reducing it to 12.5%. To reach this goal Group Health needed to have a lot of adult smokers quit (about 40 000) and they would have to prevent many teens from starting to smoke (Table 4). The current tobacco use prevalence at Group Health is about 14%. Table 4. Analysis of Group Health’ efforts to reduce tobacco use by building block Building block Leadership and governance Action • Created a tobacco reduction team made up of physicians, nurses, planners and researchers. This group: − created a series of recommendations, including better systems for identification of tobacco users, systematic advice to quit and full coverage for counselling and medication; − gathered organizational support for the initiative in order to make and keep tobacco cessation a priority with health plan administrators; − developed a tobacco dependence treatment programme through collaboration with researchers; − established a “number needed to treat” (NNT) metric and showed administrators that tobacco dependence treatment was more effective than most other preventive (and chronic care) treatments and kept tobacco cessation a priority. • Developed measurable goals and specific objectives at multiple levels of the organization, including prevalence of smoking, compliance with asking and advising, and use of cessation programmes. People were held accountable for achieving goals, including having them written into their job descriptions.
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Strengthening health systems for treating tobacco dependence in primary care / Part II
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Building block Health workforce
Action • Recognized that the physicians could not do it all and identified individuals at different levels of the organization and trained them to: − identify tobacco users; − educate tobacco users about why they should quit; − provide advice to quit; − refer to existing cessation resources (both telephone-based and in-person group programmes); − follow up at next health-care visit. • Provided continued efforts to support providers to reach more and more tobacco users: − cessation articles in the health plan’s quarterly magazine; − “lunch and learns” in providers’ offices. • Ensured that there were sufficient financial and personnel resources for programmes. • Provided “rewards” in form of modest bonuses and recognition to top performers. • Where possible, access to tobacco cessation medications were provided/encouraged. • Reviewed guidelines and selected models for brief tobacco interventions, such as NCI 4A model (now 5A’s): − Ask, Advise, (Assess), Assist, Arrange. • This programme provided both group classes and individual phone-based treatment, along with quit medications. • Provided widely available and easily accessible cessation resources which made referrals by clinicians easier and more consistent. • Tobacco use as a vital sign: − first as a stamp in the patient’s paper chart; − then as a data field in an electronic health record. (This transition to an electronic health record surprisingly saw the identification of tobacco users drop dramatically. Suspecting it was not due to sudden changes in practitioner behaviour, Group Health found that the electronic system needed to be modified to support and require tobacco-related data entry.) • There are cessation programme posters and brochures in clinics and offices. This signage supports the reminder system in the chart and delivers the message to clinic staff and patients about the importance of cessation. • Developed feedback mechanisms to give those who were accountable information on how they were progressing in meeting the goals.
Financing Medical products and technologies Service delivery
Information systems
Case study 2: Beijing Chao-Yang Hospital China is home to some 320 million smokers – about a third of the world’s total – and suffers around one million tobacco-related deaths per year. Beijing Chao-Yang Hospital, an affiliate of Capital University of Medical Sciences, was established in 1958. As one of the top grade hospitals in China, Chao-Yang Hospital has played a leading and active role in tobacco control and tobacco dependence treatment (Table 5). Table 5. Analysis of Chao-Yang Hospital’s efforts to reduce tobacco use by building block Building block Leadership and governance Action • A leader and a dedicated team: − Dr. Weng Xinzhi organized the first team to work on the problem of addressing smoking in hospital settings; − set up the first smoking cessation clinic in 1996, which has led to the development of many other smoking cessation clinics in respiratory clinics in hospitals throughout China, with some of them being in primary care.
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Building block Health workforce
Action • Created smoke-free hospitals in 2004. The smoking rate among hospital employees dropped from 11.3% in 2004 to 4.9% in 2007. • A network of Medical Professionals Against Smoking has been established. • Staff is trained to intervene with tobacco users in respiratory care clinics and some primary care clinics. There continues to exist a strong need to reduce smoking prevalence among health professionals and to educate them on the treatment of tobacco dependence because: − only 7.1% of surveyed doctors (n=3650) knew how to help a smoker develop a quit attempt plan; − >97% have never used cessation medications to treat tobacco dependence; − >50% have never heard of the drugs used to treat tobacco dependence. • An annual tobacco conference is held for medical professionals. • Provide smokers wanting to quit a choice of NRT, bupropion or varenicline. • • • • Physicians in outpatient care are incorporating brief interventions into their daily clinical practice. The hospital supported patients in several communities to quit tobacco use. Provided quitline services to patients in the community Promoted hospital cessation services in some communities.
Medical products and technologies Service delivery
Information systems
• Information about tobacco dependence treatment has been added to medical text books since 2006. • Created a smoking cessation prescription that is printed automatically once the smoker is identified. It contains: − the patient’s name, sex, age, medical identification number, and other identifying information; − brief information about the harmful effects of smoking and the health benefits of quitting; − treatment method description; − choice of cessation medication; − smoking cessation clinic hours, address and hotline number; − the physician’s signature.
Practice 4. Identifying small system improvements to facilitate the delivery of brief tobacco interventions in primary care settings (30 minutes) Work in small groups, review each building block and identify small system improvements that could facilitate the delivery of brief tobacco interventions or make the process more effective or efficient. Please note your results in Worksheet 3. 5. Evaluation (20 minutes) Each group should share its findings by writing on flipchart paper or whiteboard. Please help provide your comments on other groups’ results.
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Strengthening health systems for treating tobacco dependence in primary care / Part II
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Worksheet 3.
Building blocks Service delivery
Improvements How can brief tobacco interventions be delivered routinely and effectively?
Health workforce
Which staff should deliver brief tobacco interventions?
Information support
What reminder systems would you put in place?
Medical products and technologie
How would you plan for procuring cessation medicines? What signage and educational material would you use?
Financing
How would you build in incentives? What funding sources can you tap into for delivering the brief tobacco interventions?
Leadership and governance
What policies are in place that can support the delivery of brief tobacco interventions as part of daily practice?
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Participants’ workbook
Module 4: Getting support from stakeholders Objectives Upon completion of this module participants will be able to: − identify and solicit support from stakeholders, policy-makers and champions in the organization; − anticipate stakeholder needs and refute objections (e.g. concerns about conflicting priorities, costs); − identify organizational policies and regulations that support the routine identification of tobacco users and provision of brief tobacco interventions (including smoke-free policy in the organization). Agenda 1. Who are the stakeholders and champions? (15 minutes). 2. Four steps in engaging with stakeholders (30 minutes). 3. Identifying champions (15 minutes). 4. Identifying supportive organizational policies and regulations (10 minutes). 5. Practise using the WHO Health System Framework to identify, analyse and gain support from stakeholders (30 minutes). 6. Evaluation (30 minutes). Preparation 1. Who are the stakeholders and champions? (15 minutes) To ensure a system change is successful we need: − support from relevant stakeholders; − champions; − supportive organizational policies, regulations and incentives. This module covers how to obtain support from relevant stakeholders, how to find champions, and how to identify supportive organizational policies. The incentives are discussed in Module 6. Brainstorming Who are the stakeholders that you need to involve in making system changes to improve the delivery of brief tobacco interventions in primary care? Who are champions?
Stakeholders are individuals or groups who can affect or be affected by your plan to improve the delivery of brief tobacco interventions. Champions are a stakeholder group who are deeply interested in your project and are supportive of your project.
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Presentation 2. Four steps in engaging with stakeholders (30 minutes) We can use four steps to engage with stakeholders: • Identify your stakeholders. • Prioritize your stakeholders. • Understand your key stakeholders. • Determine appropriate strategies and actions to approach your key stakeholders. 2.1 Step 1: Identify your stakeholders The first step is for you to brainstorm: • Who has influence or power over your system changes? • Who has an interest in your system changes? • Who are affected by your system changes? The key stakeholders for scaling up brief tobacco interventions in primary care settings may include: • policy-makers; • health-care providers; • patients; • public health department/Ministry of Health; • NGOs; • community members. Once again, the WHO Health System Framework can be used to identify your stakeholders and you will have a chance to do it at the practice stage. 2.2 Step 2: Prioritize your stakeholders The first step often results in a long list of potential stakeholders. The second step is to decide who the key stakeholders are. The influence/interest grid (Figure 4) can help you map out your stakeholders, classifying them by their influence over the planned system changes and by their interest in the system changes. In general, those people with high influence and high interest are your priority stakeholders. Figure 4. Influence/interest grid for stakeholder prioritization
High
Influence
Low Low Interest High
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2.3 Step 3: Understand your key stakeholders In order to gain support from the stakeholders, we need to know about our stakeholders’ perspectives and needs.
Strengthening health systems for treating tobacco dependence in primary care / Part II
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• • • •
How would this stakeholder define a positive outcome for your planned systems changes? What can this stakeholder gain from an improved system for tobacco dependence treatment? What are the barriers or challenges that would limit this stakeholder’s participation in this programme? What would be an incentive for this stakeholder to participate in this programme?
The best way of answering these questions is to talk to your stakeholders directly. People are often quite open about their views. 2.4 Step 4: Determine appropriate strategies and actions to approach your key stakeholders After the stakeholder analysis you can easily realize what strategies and actions you have to take with different stakeholders and how best to communicate with them. For example, according to a stakeholder’s position on the influence/interest grid you can take the following different strategies and actions: • High influence, interested people: you should fully engage and make the greatest efforts to satisfy them. • High influence, less interested people: put enough work in with these people to keep them satisfied, but not so much that they become bored with your message. • Low influence, interested people: keep these people adequately informed, and talk to them to ensure that no major concerns arise. • Low influence, less interested people: monitor these people, but do not bore them with excessive communication. You will need to anticipate stakeholders’ concerns and be well prepared to address these concerns before you approach the stakeholders. One issue stakeholders may bring up is cost, and other disease priorities (HIV, tuberculosis, diabetes, cardiovascular disease). The following data can help you justify the cost and prioritization for tobacco dependence treatment. • Brief and intensive tobacco use treatments have been shown to be not only clinically effective but also extremely cost-effective relative to other commonly used disease prevention interventions and medical treatments (Table 6). • Treating tobacco dependence can prevent the development of a variety of costly chronic diseases, including heart disease, cancer and pulmonary disease. Treatment of tobacco dependence is an essential part of any disease prevention and management programme, which cannot be separated and can help reduce the disease burden. Table 6. Numbers needed to treat (NNT) to achieve certain outcomes for various interventions Intervention Statins Antihypertensive therapy Cervical cancer screening GP brief advice to stop smoking < 5 minutes GP brief advice + pharmacological support GP brief advice + pharmacological support + behavioural support Outcome Prevent one death over five years Prevent one stroke, myocardial infarction, death over one year Prevent one death over 10 years Prevent one premature death Prevent one premature death Prevent one premature death NNT 107 700 1140 80 38−56 16−40 41
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3. Identifying champions (15 minutes) Brainstorming • How can champions effect system changes? • How do you identify champions? • What are the qualities of a successful champion?
3.1 How can champions effect system changes? Champions can contribute to the success of the planned system changes by: − advocacy (take part in advocacy events, give presentations or talk informally to colleagues to encourage their participation); − support(act like a leader, help remove roadblocks, ensure that resources are available); − acting as resource persons (provide practical advice or conduct capacity development to facilitate the implementation of system changes). 3.2 Practise ways of identifying champions • Identify champions through stakeholder analysis. Participants can easily see which stakeholders are likely to be advocates and supporters for your project after stakeholder analysis. Those high-influence, interested people will champion your project if opportunities arise. • Send out a call for participation. Often champions will identify themselves by responding to your call for participation. • Ask organizational or department managers to identify and nominate. 3.3 Qualities of a successful champion Successful champions should be: − well established in their work group, knowledgeable about the group’s activities, and respected by their colleagues; − helpful and approachable to their colleagues; − able to communicate effectively with peers, superiors and subordinates. In fact, any of the stakeholders can also be champions for supporting the change. The WHO Health System Framework can be a useful tool to identify champions for you. Below are examples of potential champions for each of the building blocks: Service delivery – clinic staff, clinic managers, patients. Health workforce – clinic staff, educators, community health workers. Information support – information system and medical records managers. Medical products and technologies – pharmacy, pharmaceutical companies. Financing – business office, directors, policy-makers. Leadership and governance – policy-makers, government agencies.
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4. Identifying supportive organizational policies and regulations (10 minutes) Implementing and institutionalizing a system change for tobacco dependence treatment is dependent on supportive organizational policies and regulations (e.g. smoke-free policy in primary care facilities). If they do not exist, we should get policy-maker and stakeholder support to develop new policies/ regulations. All stakeholders need buy in to accept new policies. Practice 5. Practise using the WHO Health System Framework to identify, analyse and gain support from the stakeholders (30 minutes) Work in small groups to: − identify stakeholders who may influence changes in each of the WHO building blocks (each group works one block); − map out the stakeholders on the influence/interest grid; − select one key stakeholder and analyse this stakeholder’s perspective regarding incentives and challenges/barriers for supporting changes; − write a message to gain the stakeholder’s support. Please note your results in Worksheet 4. 6. Evaluation (25 minutes) Each group presents its stakeholder message. Everyone helps critique and adds to the message. Please note that this exercise is the beginning of developing a communication plan to engage with stakeholders, which typically includes the following components: an objective (why to communicate); a message to win support (what to communicate); a strategy (how to communicate); a start time (when to communicate); a spokesperson (who to communicate). A good stakeholder communication plan is essential to the success of any new system change design and implementation. You may consider completing your communication plan using the template in Table 7. Table 7. A template for the stakeholder communication plan Objective Message to win support Strategy Start time Spokesperson
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Worksheet 4.
WHO building blocks Service delivery
List the stakeholders
Key stakeholders
Incentives for participation
Barriers to participation
Message
Information support
Message
Medical products and technologies
Message
Leadership and governance
Message
Financing
Message
Health workforce
Message
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Module 5: Community participation Objectives Upon completion of this module participants will be able to: − distinguish consumer from community; − identify stakeholders, champions, and partners in the community; − identify resources available in the community; − identify opportunities to work with community partners. Agenda 1. A consumer-community continuum (20 minutes). 2. The goals of community participation in promoting brief tobacco interventions (30 minutes). 3. Practise identifying, assessing and promoting community involvement (30 minutes). 4. Evaluation (30 minutes). Preparation 1. A consumer-community continuum (20 minutes) Community participation is a core principle underpinning the development of primary care. A successful primary care programme depends on community involvement. A community can play a variety of roles in providing or supporting services to treat tobacco dependence. Work with the person sitting next to you to make a list of: − consumers of your primary care organization; − members of the community served by your organization.
Communities are not simply groupings of consumers. Community can be understood along a continuum, with consumers and community organizations at different ends. Primary care organizations are required to be responsible to the whole community and not only to consumers. Consumers are part of the whole community and the priority of community involvement for promoting tobacco dependence treatment must be on the key community organizations that you have listed above, such as the thematic NGOs (e.g. cancer and heart associations) or government organizations. Presentation 2. The goals of community participation in promoting brief tobacco interventions (30 minutes) The goals of community participation in strengthening health systems to deliver brief tobacco interventions in primary care are to see: − tobacco dependence treatment high on the agenda of the community; − increasing demand from tobacco users through public education; − utilization of community resources in supporting the delivery of brief tobacco interventions.
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Brainstorming As a service manager, how can you promote community involvement to meet these goals?
This has been partly discussed during Module 4. In summary, you will need to: − identify, assess and promote active involvement of key community partners (leadership groups/ organizations); − identify and promote utilization of community resources.
2.1 Identifying community partners Refer to Module 4. 2.2 Assessing the level of community involvement The level of community involvement can be assessed along a continuum of decision making power (Table 8). 2.3 Promoting community involvement Different levels of involvement are possible at any given time. We should always work towards attaining the highest level. The following possible behaviours can help you work towards attaining the highest level of involvement, where communities initiate and share all aspects of the decision-making process: − information (keeping people informed); − consultation (getting feedback, listening to ideas); − decision-making (joint decision-making, acting together, forming a partnership to carry out plans); − supporting independent community interests. Table 8. Level of community involvement Quality Manipulation: Communities are manipulated. Description • Communities do understand the issues. • Communities are not given feedback on action taken. • Problem analysis is not shared with community members. • Communities are not involved with the root of the problem; participation is incidental. • Communities appear to have been given a voice but, in reality, have little or no choice about the subject matter. • Communities have little or no opportunity to formulate their own opinions.
Decoration: Communities are used as needed. Tokenism: Communities are used in a perfunctory or merely symbolic way to give the appearance of real participation.
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Quality Communities are assigned but informed
Description • Communities are given complete, accurate information about their actions, and understand why their participation is needed. • They know who made the decision concerning their involvement and why. • They have a meaningful role to play in the development of a project. • They volunteer for a project after having been given all the necessary information. • Projects are run and designed by external agencies, but communities understand the process and their opinions are treated seriously. • Decisions are initiated externally. • Communities have a high degree of responsibility and are involved in the production and design aspects of projects. • Communities contribute their opinions before projects are implemented. • External agencies do not interfere or direct community run projects. • The community develops decisions and projects. • Actions are implemented by the community.
Communities are consulted and informed Communities participate in project implementation
Communities initiate and direct decisions Communities initiate, plan, direct and implement decisions
Practice 3. Practise identifying, assessing and promoting community involvement (30 minutes) Work in small groups, as follows: • Identify community leadership groups/organizations for achieving the above-mentioned three goals of community participation. • Assess your current level of involvement with the identified community leadership groups/ organizations. • Map out the capacities/resources of the community leadership groups/organizations in achieving each of the three goals. • Assess the community leadership groups/organizations’ attitudes towards collaboration and participation in tobacco dependence treatment programmes. • Brainstorm ways of encouraging and soliciting community participation (financial support, donated labour, in-kind material support, monitoring, professional experience, other). Please note your results in Worksheet 6. 4. Evaluation (30 minutes) Each group shares its results by writing on the flipchart paper or whiteboard. Everyone adds to the discussion and gives feedback on the results. Please note that you have actually developed a community participation plan by completing Worksheet 6.
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Worksheet 6. Goal of community participation List of leadership groups/organizations that you need to engage with Current level of involvement Capacities/resources
Attitudes towards collaboration and participation
Strategies to promote involvement
Tobacco dependence treatment high on the agenda of the community Participants’ workbook
Strengthening health systems for treating tobacco dependence in primary care / Part II
Increasing demand from tobacco users
Utilization of community resources in supporting delivery of brief tobacco interventions
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Module 6: Sustaining a system change: feedback, motivations and incentives Objectives Upon completion of this module participants will be able to: − define workplace motivation and incentives; − describe effective incentive systems; − use the WHO Health System Framework to identify effective incentives for primary care providers to routinely deliver brief tobacco interventions; − build an incentive plan for their primary care organization. Agenda 1. Why motivation and incentives are important? (30 minutes). 2. Definition and components of workplace motivation (10 minutes). 3. Incentives and effective incentive systems (15 minutes). 4. Practise using the WHO Health System Framework to identify effective incentives (30 minutes). 5. Evaluation (25 minutes). Preparation 1. Why motivation and incentives are important? (30 minutes) Brainstorming Why are incentives an important part of implementing a system change to promote brief tobacco interventions?
Primary care providers may have heavy workloads or conflicting priorities. Group exercise Work in small groups to generate a list of workplace incentives that you know are effective.
What was your experience of the exercise?
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Participants’ workbook
Presentation 2. Definition and components of workplace motivation (10 minutes) In the workplace, motivation is a management skill to improve job performance and job satisfaction. Workplace motivation is defined as the tendency to initiate and sustain effort towards a goal, which is an internal state consisting of three components: − perceived task importance; − self-efficacy; − expectancy of personal reward. Perceived task importance refers to the value someone places on the work, or tasks that they are being asked to perform. If one believes that the value of one’s work is extremely high, one may endure hardships for low pay in order to achieve a goal. Self-efficacy refers to the extent to which we believe we can be successful at our work. If we think we have no chance of success, we are unlikely to be highly motivated to initiate and sustain a particular task. Expectancy of personal reward is our anticipation of what will happen to us if the work goal is reached. Will anyone notice? Will anyone care? Will we be rewarded? In all cases, work tasks involve some effort on the part of workers. Workers expect something in return. Motivation is likely to suffer when workers think that nobody will notice their hard efforts or when they see workers whose productivity is low receiving rewards equal to those who try harder. Enhanced motivation leads to improved performance, while increased job satisfaction leads to reduced turnover (greater retention). 3. Incentives and effective incentive systems (15 minutes) 3.1 Definition of incentives Motivation is intrinsic, but you can influence motivation with extrinsic changes in the workplace. Of the available methods of improving motivation, providing incentives is the most reliable to improve workplace motivation. Incentives are defined as the factors/conditions within health professionals’ environments that enable and encourage them to improve their performance and to stay in their job. 3.2 Effective incentive systems There is evidence that using a range of incentives is important if workers’ motivation and behaviour are to be influenced. Therefore, it is better to implement an incentive system. Incentive systems that are most likely to be effective and sustainable feature the following characteristics. They: − embrace the principles of transparency, fairness and consistency; − fit the purpose and are based on reaching a specific goal; − include both financial and non-financial incentives; − are sustainable and remain effective; − are appropriate to the target population; − involve input from all relevant stakeholders when designing the incentive system.
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Participants’ workbook
3.3 What works in developing countries? There are low-cost methods of providing incentives, such as recognition systems, posting job performance and budget re-allocation. Below are three case studies in developing-country settings: • In Haiti, a programme has provided rewards to organizations that meet or exceed health outcome targets. In many of the organizations, the rewards “trickled down” to individual workers in the form of bonuses or recognition. • A survey of reward systems in developing countries suggests that they be group-based rather than targeted at individuals, and that recognition should emphasize positive effects on the community. • In Kyrgyzstan, public posting of performance data paired with supervisory recognition improved provider performance in counselling on sexually transmitted infections. 3.4 Using the WHO Health System Framework to identity incentives The WHO Health System Framework is a useful tool for you to identify incentives that relate to each of the six building blocks. By doing so, you can find ways to reward success considering each component of the system. Practice 4. Practise using the WHO Health System Framework to identify effective incentives (30 minutes) Work in small groups and brainstorm a list of incentives that relate to each of the six building blocks to motivate primary care providers to routinely deliver brief tobacco interventions. Consider how can you leverage the perceived importance of the task, self-efficacy and expectancy? Please note your ideas in Worksheet 7. 5. Evaluation (25 minutes) Each group to share your effective incentives. Everyone provides comments and suggestions to fine tune the incentive systems.
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Participants’ workbook
Worksheet 7.
WHO building blocks Service delivery
Incentives
Information support
Medical products and technologie
Leadership and governance
Financing
Health workforce
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Participants’ workbook
Module 7: Your action plan to implement a system change Objectives Upon completion of this module participants will be able to: − describe the importance of planning in initiating successful system changes; − describe the steps of creating an action plan; − develop an action plan and deliver a presentation that summarizes their action plan; − present a synthesis of the knowledge and skills gained during training to demonstrate new insight about the process of strengthening health systems for delivery of brief tobacco interventions using the WHO building blocks. Agenda 1. The importance of planning in initiating successful changes (20 minutes). 2. Definition and components of an action plan (15 minutes). 3. Five steps to creating an action plan (25 minutes). 4. Making an action plan for implementing system changes (60 minutes). 5. Presenting action plans (60 minutes). Preparation: 1. The importance of planning in initiating successful changes (20 minutes) Group exercise: Work in small groups. Your group will need to build the tallest tower in five minutes using five sheets of A4 paper and five centimetres of tape. After the exercise, you will see that the group that has planned its structure is most likely to have the tallest tower made out of paper. This module will give you opportunities to learn and practise how to make a solid action plan for implementing a system change to improve the delivery of brief tobacco interventions in your primary care system. Presentation 2. Definition and components of an action plan (15 minutes) Brainstorming • What is an action plan? • What does an action plan look like?
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Participants’ workbook
An action plan can be defined as: − a planned series of actions, tasks or steps designed to achieve an objective or goal; − a written document that individuals, groups, and organizations develop to guide their efforts in certain initiatives. The key aspects of an action plan should include: − a statement of the problem you want to resolve/what change do you want to bring about; − objectives; − planned activities/solutions for your problem; − timelines; − the expected resource needs. 3. Five steps to creating an action plan (25 minutes) There are five steps to creating an action plan to change each of the six health system building blocks. • Define the issue or problem to be addressed (you have already completed this step in Module 2). • Identify opportunities and challenges to bring about the desired changes. • Set objectives. • Construct action steps (list of actions, timelines, responsible persons). • Format your action plan. 3.1 Identify opportunities and challenges to bring about the desired changes Once you have defined problems to be addressed through a plan of action, the next step is to evaluate the problem more objectively and thoroughly, noting especially opportunities and challenges for you to address to bring about desired changes. The information on the opportunities and challenges can help you generate appropriate action steps later on. 3.2 Set objectives Setting objectives is a key step for creating a successful action plan because: • Objectives function as a kind of thesis statement for the action plan. They explain exactly what the intended tasks will be in order to address the selected problem/issue. • In addition to giving a focus for creating an action plan, objectives show stakeholders the results we expect to achieve. One way to write objectives that convert to successful action steps is to make objectives SMART. SMART stands for: Specific (What exactly are we going to do for whom?) Measurable (Is it quantifiable and can we measure it?) Attainable/achievable (Can we get it done within the proposed time frame with the resources and support we have available?) Relevant (Will this objective have an effect on the desired goal or strategy?) Time bound (When will this objective be accomplished?)
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Participants’ workbook
You can use the following template to write a SMART objective: By_____/_____/_____, _________________________ [WHEN − Time bound] [WHO/WHAT − Specific] from _________ to _____________________________________ [MEASURE (number, rate, percentage of change and baseline) − Measurable] Here is an example: By 31/12/2010 (time bound), increase the number of training workshops given to primary care providers on the 5A’s brief tobacco intervention model (specific and relevant) from 2 to 10 (measurable and achievable). Write a SMART objective:
3.3 Construct action steps Developing the action steps is the most crucial part of the action plan. The action steps are a realistic list of solutions and activities that will address the problem or bring about the desired change. The action steps should contain at least five things: − what; − by whom; − by when; − the intended outcome of action; − the expected resources needed. Please use the following action step chart to develop your action steps: What By whom By when Resources needed Non-financial Example: Meet with the director of a community agency Primary care service By the end of manager December 2010 Budget To get the community agency interested in participating in the tobacco dependence treatment programme Expected outcome
A meeting room, US$ 10 background materials on tobacco use in the community
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Strengthening health systems for treating tobacco dependence in primary care / Part II
Participants’ workbook
3.4 Format your action plan Your action plan will need to be put into a formal document for you to distribute it. Here is the suggested action plan format: − title; − the issue or problem that needs to be addressed; − challenges and opportunities in addressing the problem; − objectives; − action steps; − monitoring and evaluation. Practice 4. Making an action plan for implementing system changes (60 minutes) Refer to Worksheet 2 and work in small groups to: − select one needed change in any of the six building blocks that could improve the delivery of brief tobacco interventions; − make an action plan for implementing the selected change; − prepare an 8−10 minute presentation to present the action plan. The group presentation should include: − a description of the issue or problem that needs to be addressed in your primary care setting; − challenges and opportunities in bringing about the desired change; − your SMART objectives; − a list of action steps; − monitoring and evaluation; − the stakeholders and/or champions for implementing the planned system change; − how you will involve the community. Evaluation 5. Presenting action plans (60 minutes) Each group presents its action plan. Everyone listens and gives feedback and comments. Please note that your action plan is pointless unless you make every effort to actually implement it. Therefore, your next steps are implementation and monitoring and evaluation.
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REFERENCES AND RESOURCES 1. The tobacco atlas. 1st ed. Geneva, World Health Organization, 2002 http://www.who.int/tobacco/resources/publications/tobacco_atlas/en/, accessed 21 October 2012. 2. Curbing the epidemic: governments and the economics of tobacco control (Development in Practice Series). Washington, DC, The World Bank, 1999. 3. Fiore MC et al. Treating tobacco use and dependence: 2008 update. Clinical practice guideline. Rockville, MD, Department of Health and Human Services, 2008. 4. Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database of Systematic Reviews, 2008, (2):CD000165. (DOI: 10.1002/14651858.CD000165.pub3). 5. Ask, Advise, Act model. http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hsarchive&part=A34776 6. New Zealand smoking cessation guidelines. Wellington, Ministry of Health, 2007 http://www.moh.govt.nz/moh.nsf/indexmh/nz-smoking-cessation-guidelines#availability, accessed 21 October 2012. 7. Basics of tobacco cessation. http://www.whcrc.org/tcrc/HCPTrng/TheBasicsofTobaccoCessation.pdf 8. Puska PMJ et al. The participation of health professionals in a smoking-cessation programme positively influences the smoking cessation advice given to patients. International Journal of Clinical Practice, 2005, 59(4):447−452. 9. Omole OB, Ngobale KN, Ayo-Yusuf OA. Missed opportunities for tobacco use screening and brief cessation advice in South African primary health care: a cross-sectional study. BMC Family Practice, 2010, 11:94. 10. Primary health care in action. Geneva, World Health Organization, 2008 (http://www.who.int/whr/2008/media_centre/country_profiles/en/index.html, accessed 3 January 2010). 11. The World Health Report 2008. Primary health care – now more than ever. Geneva, World Health Organization, 2008 (http://www.who.int/whr/2008/en/index.html, accessed 3 January 2012). 12. Boyle R, Solberg L, Fiore M. Use of electronic health records to support smoking cessation. Cochrane Database of Systematic Reviews, 2011, (12):CD008743. (DOI: 10.1002/14651858.CD008743.pub2). 13. Carson KV, Verbiest MEA, Crone MR, Brinn MP, Esterman AJ, Assendelft WJJ, Smith BJ. Training health professionals in smoking cessation. Cochrane Database of Systematic Reviews, 2012, (5): CD000214. (DOI: 10.1002/14651858.CD000214.pub2). 14. Reda AA et al. Healthcare financing systems for increasing the use of tobacco dependence treatment. Cochrane Database of Systematic Reviews, 2009, (2):CD004305. (DOI: 10.1002/14651858.CD004305.pub3). 15. Global tuberculosis control 2009: epidemiology, strategy, financing. Geneva, World Health Organization, 2009. 16. WHO CVD-risk management package for low- and medium-resource settings. Geneva, World Health Organization, 2002 (http://whqlibdoc.who.int/publications/2002/9241545852.pdf, accessed 3 January 2010). 17. Samb B et al. Prevention and management of chronic disease: a litmus test for health-systems strengthening in low-income and middle-income countries. Lancet, 2010, 376(9754):1785−1797. 18. WHO (2004). Code of practice on tobacco control for health professional organizations. Geneva, World Health Organization, 2004 (http://www.who.int/tobacco/communications/events/codeofpractice/en/, accessed 16 November 2011). 19. Anderson P, Jané-Llopis E. How can we increase the involvement of primary health care in the treatment of tobacco dependence? A meta-analysis. Addiction, 2004, 99(3):299−312. 20. Fiore, MC, Keller PA, Curry SJ. Health system changes to facilitate the delivery of tobacco dependence treatment. American Journal of Preventive Medicine, 2007, 33(Suppl 6):S349−S356. 21. Côté, MJ. Understanding patient flow. Decision Line, 2000, 31(2), 8−10. 22. Great Britain Parliament House of Commons Health Committee. Health inequalities: Vol. 2 Written evidence. House of Commons papers 422-II 2007-08 (http://www.parliament.the-stationery-office.co.uk/pa/cm200708/cmselect/cmhealth/422/422ii.pdf, accessed 3 January 2010).
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References and resources
23. Thompson R. Stakeholder analysis (http://www.mindtools.com/pages/article/newPPM_07.htm, accessed 16 November 2011). 24. Community Participation. In: Guidebook for planning education in emergencies and reconstruction. Paris, International Institute for Education Planning, 2006 (http://www.iiep.unesco.org/fileadmin/user_upload/Research_Highlights_Emergencies/Chapter32.pdf, accessed 16 November 2011). 25. Neuwelt P. Community participation toolkit: a resource for primary health organizations. Wellington, Steele Roberts Publishing Limited, 2007. 26. Sanoff H. Community participation methods in design and planning. New York, NY, John Wiley & Sons Inc, 2000. 27. Luoma M. Increasing the motivation of health care workers. Technical Brief 7. Chapel Hill, NC, The Capacity Project, 2006. http://www.capacityproject.org/images/stories/files/techbrief_7.pdf, accessed 16 November 2011). 28. Incentive systems for health care professionals. International Council of Nurses, International Hospital Federation, International Pharmaceutical Federation, World Confederation for Physical Therapy, World Dental Federation, World Medical Association, 2008 (http://www.whpa.org/PPE_Fact_Incentive_Pro.pdf, accessed 16 November 2011). 29. Planning/adapting exercises. (Internet blog). http://www.huddle.com/blog/building-teamwork-10-quick-andeasy-team-building-exercises-for-improving-planning-skills-and-building-trust-part-2/, accessed 18 November 2011). 30. Wikipedia foundation. Action plan (http://en.academic.ru/searchall.php?SWord=action+plan&stype=0, accessed 18 November 2011). 31. Bonner Curriculum. Action planning: developing a plan. (http://publichealth.columbus.gov/WorkArea/DownloadAsset.aspx?id=33787, accessed 18 November 2011). 32. Evaluation guide: writing SMART objectives. Atlanta, Centers for Disease Control and Prevention (http://www.cdc.gov/dhdsp/programs/nhdsp_program/evaluation_guides/docs/smart_objectives.pdf, accessed 16 November 2011).
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Appendix: Sample evaluation form
APPENDIX: SAMPLE EVALUATION FORM Please select the answer you most agree with. Please also give your written feedback in the space provided. 1. Overall I found the training workshop useful for my work Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 2. Which part of the training workshop did you find the most useful?
3. Which part of the training workshop did you find the least useful?
4. The workshop facilitator had a good knowledge of the subject Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 5. The workshop facilitator’s skills in conveying the subject matter were good Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 6. As a result of my participation in the training workshop, I feel more confident to plan and implement system changes to support the delivery of brief tobacco interventions Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree 59
Strengthening health systems for treating tobacco dependence in primary care / Part II
Appendix: Sample evaluation form
7. How difficult did you find the training workshop? Too difficult Difficult Just right Easy Too easy 8. How could the workshop implementation be improved?
9. How could the training materials be improved?
10. Overall, how would you rate the workshop? Very good Good Average Poor Very poor 11. Any other comment, suggestion, criticism:
Thank you for your feedback!
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For further information, kindly contact PND as follows: Prevention of Noncommunicable Diseases (PND) World Health Organization 20, Avenue Appia CH-1211 Geneva 27 Switzerland Tel.: + 41 22 791 21 11 Fax: + 41 22 791 48 32 Email: pnd@who.int http://www.who.int/tobacco/en/