Missed
0pportunities
for Anti-Smoking
Education
at Gommunity
Health
Centres
in the Gape
Metropolitan
Area.
Pather, MK
MB, ChB, MFamMed
(Stell)
Department
of Family
Medicine
and Primary
Care
University
of Stellenbosch,
Tygerberg;
and Community
Health Services
Organisation,
Department
of Health
and Social
Services,
Provincial
Admin
istration
Western Cape
DeVilliers, PfT
M B , C h B , D O M , H o n s B S c M e d S c i
(Epid),
MFamMed,
PhD (Stell)
D e p a r t m e n t
o f F a m i l y
M e d i c i n e
and Primary Care
University
of StellenboschTygerberg
B a r n e s r J M
BSc,
MSc (Stell)
Department
of Community
Heakfi
,
University
of Stellenbosch,lygerberg
Key words:
s m o k i n g ,
m i s s e d
o p p o r t u n i t i e s ,
education,
prevention,
screening
Correspondence
to:
Dr. MK Pather
Department
of Family Medicine
and Primary Care, University
of
S t e l l e n b o s c h ,
P . O .
B o x 1 9 0 6 3
Tygerberg
7505,
South
Africa
E-mail:
mpather@gerga.sun.ac.za
Tel:02l-9389449
Fax:
02 | -9389
| 53
Objectives-To determine
the extent
of missed opportunities
regarding
antismoking
education
for people l5
y e a r s a n d o l d e r , w h o a t t e n d
Community Health Centres (CHC)
in the CapeTown
Metropolitan
Area
for reasons
unrelated
to smoking
cessation.
M e t h o d s - A D e s c r i p t i v e
C r o s s
-sectional
Survey
was conducted
using
6 randomly
selected
CHC. A sample
o f 1 3 5 8 p a t i e n t s
w a s s e l e c t e d
o f
whom 850 were smokers.
R e s u l t s - T h e o v e r a l l s m o k i n g
prevalence
was 62,6
%
(95%Cl60,0%-65,2%).
Of the total group 652 (76,7
%; 95%Cl 7 3,86%-78,54%)
indicated
t h a t t h e y d i d n o t r e c e i v e a n y
a n t i s m o k i n g
a d v i c e d u r i n g th e i r
attendance
at CHC. ln addition.
601
(8 1,9
%; 95%Cl
7 8,43%-85,37%)
of the
7 3 4 p a t i e n t s s e e n b y a d o c t o r
indicated
that they did not receive
antismoking
advice
from their doctor.
Of the I l6 patients
seen
by a primary
health
care sister,
67 (57,8%;95%Cl
48.82%-66,78%) indicated that they d i d n o t r e c e i v e a n y a n t i s m o k i n g advice on the day of their visit. Of
I l2 asthmatic patients who smoked, 80 (7 1,4 %; 95%Cl 63,04%-79,7 6%) did not receive any antismoking advice on the index day of their visit t o t h e C H C . T h e r e c o r d a u d i t revealed that 592 (69,6 %;95%Cl 6 6 , 5 1 % - 7 2 , 6 9 % ) o f p a t i e n t s presented with a smoking related p r e s e n t i n g c o m p l a i n t a n d 6 4 | ( 7 5 , 4 % ; 9 5 % C l 7 2 , 5 | - 7 8 , 2 9 % ) patients did not have their smoking status recorded in their folders. Conclusions -Opportunities for antismoking education are missed in patients attending CHC. All patiens attending CHC and especially those i n h i g h - r i s k g r o u p s s h o u l d b e routinely educated against smoking, i r r e s p e c t i v e o f t h e i r p r e s e n t i n g complai nts. Such educational efforts should be recorded prominently in the patient's record.
Abstract
S A Fom Prod 2000;22(6):9-l 4I n t r o d u c t i o n
T o b a c c o s m o k i n g i s t h e m o s t i m p o r t a n t c a u s e o f p r e v e n t a b l e d i s e a s e a n d p r e m a t u r e d e a t h i n d e v e l o p e d c o u n t r i e s r a n d t h e c o n t r o l o f c i g a r e t t e s m o k i n g c o u l d a c h i e v e m o r e t h a n a n y o t h e r s i n g l e m e a s u r e i n t h e f i e l d o f p r e v e n t i v e m e d i c i n e . 2The deleterious effects of smoking on h e a l t h h a v e b e e n e x t e n s i v e l y documented and smoking is considered by the World Health Organisation to be the single most important cause of preventable morbidity, mortality and disability3. Smoking related diseases are t h e m a j o r c a u s e o f d e a t h i n t h e
d e v e l o p e d c o u n t r i e s , a n d w h i l e smoking rates are declining in these c o u n t r i e s , to b a c c o c o n s u m p t i o n is increasing in developing countries.a T h e b l a c k p o p u l a t i o n o f S o u t h e r n A f r i c a h a s y e t t o e x p e r i e n c e i t s epidemic of smoking related diseases.
Yach and Martin have shown that the prevalence (1992) of smoking among adults in the South African context is 31,5% s and more recent prevalence f i g u r e s r e v e a l t h a t t h e " c o l o u r e d " p o p u l a t i o n g r o u p h a d t h e h i g h e s t smoking rate nationally at 59%, an i n c r e a s e o f 1 2 % s i n c e 1 9 9 2 . 6 In South Africa and specifically the W e s t e r n C a p e a n a l a r m i n g l y h i g h smoking prevalence was found in black and "coloured" men,where SASPREN? in a primary care survey showed that 68.6% and 73.3% respectively were current smokers (ages 25 to44years). Health workers and especially doctors a r e i n a u n i q u e p o s i t i o n t o h e l p smokers become ex-smokers. Patients want to talk to doctors about their health, and they expect to get help and guidance from their doctor.sThey think the doctor is the most reliable source of health information.e lf doctors do not advise patients to stop smoking, smokers may interpret the doctor's silence to mean that smoking cessation is not important, or that the smoker does not have the ability to quit.r0
Health workers should be constantly identifying smokers and encouraging t h e m t o q u i t s i n c e n o o t h e r i n t e r v e n t i o n i s a s c o s t - e f f e c t i v e . r r ' 1 2 Controlled trials have shown that a small but appreciable proportion (about 5 %) of smokers would quit smoking after simple but firm advice from their G P . r r Y e t t h e a v e r a g e p r a c t i t i o n e r s e l d o m r a i s e s th e i s s u e o f s m o k i n g during a consultation. GP's frequently do not know which of their Datients smoke and as often fail to advise them to stop even when this is part of the treatment.
H i g h e r q u i t t i n g r a t e s h a v e b e e n reported in patients who had their smoking state recorded.r3 Perhaps the time has come to design record folders which give as much prominence to a smoking habit entry as is now given to allergies and immunisation state. Such an innovation might act as a reminder to GP's of the important potential for health education,which exists at every consultation.ra Sanders and colleagues found a low level of participation by p r a c t i c e n u r s e s i n a n t i - s m o k i n g education and suggested that the main
reasons for this were:a lack of relevant training; nurses' lack of confidence in t h e i r o w n e f f e c t i v e n e s s ; a n d t h e definition of the practice nurse's role a s b e i n g p r e d o m i n a n t l y c o n f i n e d to t r e a t m e n t r o o m d u t i e s . l s T h e y s u g g e s t e d fu r t h e r t h a t t h e m o s t appropriate role for the prevention nurse, is not in giving initial advice to s t o p , ( w h i c h m a y b e b e s t d o n e opportunistically by the GP), but in the provision of longer term support and follow-up, which may be necessary to achieve sustained cessation.ls Similar work has been done in Cape Town where Strebel, Kuhn and Yach looked at determinants of cigarette s m o k i n g i n t h e b l a c k t o w n s h i p population and emphasised the need for p r i m a r y p r e v e n t i o n o f s m o k i n g i n women and boys.16
T h i s s t u d y a i m s t o d e t e r m i n e t h e proportions of missed opportunities regarding anti=smoking education for coloured people l5 years and older,who attend Community Health Centres in the CapeTown Metropolitan area for reasons unrelated to smoking cessation.
M e t h o d s
This was a Descriptive Cross-sectional Survey.
Missed opportunity was defined to exist for a particular patient if all of the following criteria were present: i n t e r v e n t i o n r e g a r d i n g s m o k i n g cessation was indicated, the patient was receptive to such intervention but did not receive such intervention. T h e t a r g e t p o p u l a t i o n i n c l u d e d a l l patients | 5 years and older attending CHC'S in the Cape Metropolitan Area. The sampling unit is the individual CHC. The CHC at which the investigator work was excluded to prevent biasJhe f o l l o w i n g 6 C H C w e r e r a n d o m l y s e l e c t e d : E l s i e s R i v e r ( E R C H C ) ; H e i d e v e l d ( H C H C ) ; H a n o v e r P a r k (HPCHC); Lotus River (LRCHC); Micchells Plain (MPCHC) and Retreat (RCHC).
A smoking related complaint exists w h e n t h e c o m p l a i n t o f a s m o k e r i s known to be associated with smoking and/or is directly aggravated by tobacco s m o k i n g . O n l y t h o s e p a t i e n t s , w h o consulted either a doctor or a primary health care sister at the CHC, were included. Patients had to be able to c o n v e r s e i n A f r i k a a n s o r E n g l i s h . Patients under | 5 years of age, those a t t e n d i n g f o r r e p e a t p r e s c r i p t i o n , dressings, and emerSency patients were excluded. Every third patient seen by a medical officer or primary health care sister was interviewed. An attempt was made to interview patients in private using a structured self-administered q u e s t i o n n a i r e . F i v e p r o f e s s i o n a l t e a c h e r s w e r e s e l e c t e d f r o m t h e community to become field workers and trained to conduct interviews. The t e c h n i q u e o f e x i t - i n t e r v i e w s w a s
e m p l o y e d . I n f o r m e d c o n s e n t w a s obtained from all patients interviewed. O n l e a v i n g t h e C H C o r w h i l e w a i t i n g a t t h e d i s p e n s a r y , p a t i e n t s w e r e a s k e d t o c o m p l e t e a q u e s t i o n n a i r e e l i c i t i n g th e f o l l o w i n g i n f o r m a t i o n : i. Demographic data.
ii. The presenting complaints. iii. The smoking status of such patients. iv. Whether they have received any
smoking education at that visit or previous visits.
v. Whether they would have liked such intervention from the CHC. v i . W h o s h o u l d p r o v i d e s u c h
intervention ?
v i i . U t i l i s a t i o n o f o t h e r a n t i - s m o k i n g aids such as pamphlets, posters and videos by the CHC staff.
The questionnaire had been subjected to a pilot study.
The responses to the questionnaire were anonymous. lf a patient indicated that a d v i c e r e g a r d i n g s m o k i n g c e s s a t i o n w o u l d b e w e l c o m e d i t w a s b r i e f l y
provided by the field worker and further s u i t a b l e a r r a n g e m e n t s m a d e f o r consultation and counselling at a later visit. An independent medical officer who remained masked to the smoking status of the patients per{ormed the record audit
The research and ethics committee of the University of Stellenbosch approved this study. Permission was also obtained f r o m t h e M e d i c a l S u p e r i n t e n d e n t responsible for the CHC to conduct the study and to audit patient records for entries regarding smoking status.
confidence intervals were calculated for proportions and rounded off to the nearest integer.
Statistical
Analysis
Results were analysed using the Epi6s t a t i s t i c a l a n a l y s i s p r o g r a m . r T Categorical variables were compared
by means of the chi-square test. P-values of less than 0,05 were regarded a s s t a t i s t i c a l l y s i g n i f i c a n t . 9 5 %
Results
Of the total sample of | 358 patients i n t e r v i e w e d , 8 5 0 w e r e s m o k e r s , b r i n g i n g t h e o v e r a l l p r e v a l e n c e a t selected CHC to 62,6 % (95% Cl: 60,0% - 65,2%\ with Hanover Park CHC 67,5% and Retreat CHC 56 % the highest and lowest respectively (Fig.l). Eleven patients refused to participate a f t e r t h e a i m s o f t h e s t u d y w e r e e x p l a i n e d . T h i s g r o u p o f e l e v e n c o n s i s t e d o f 7 s m o k e r s a n d 4 n o n -s m o k e r -s . T h e r e a s o n s c i t e d i n c l u d e d i s i n t e r e s t a n d n o t i m e . O f 8 5 0 s m o k e r s i n c l u d e d in t h e s t u d y 5 9 | ( 6 9 , 5 % ) w e r e f e m a l e a n d 6 2 , 8 % unemployed.A total of 799 (91,6%) respondents agreed that smoking is harmful to their health and 84.2 %
indicated that they had attempted to stop smoking on at least one occasion. A total of 823 (94,4 %) of patients indicated that they wanted to stop smoking and 98,7 % would try to stop if advised by their doctor. However 76,7 % of patients indicated that they d i d n o t r e c e i v e a n y a n t i s m o k i n g advice on the day of their attendance
ar cHc.
O u t o f 7 3 4 p a t i e n t s s e e n b y d o c t o r s o n t h e i n d e x v i s i t . 6 0 | ( 8 1 , 9 % ) i n d i c a t e d t h a t t h e y d i d n o t r e c e i v e a n t i s m o k i n g a d v i c e f r o m t h e i r d o c t o r ( F i g ll ) ; a n d o f t h e I l 6 p a t i e n t s s e e n b y t h e p r i m a r y h e a l t h c a r e s i s t e r s o n t h e i n d e x v i s i t ; 6 7 ( 5 7 , 8 % ) i n d i c a t e d t h a t t h e y h a v e n o t r e c e i v e d a n y a d v i c e r e g a r d i n g s m o k i n g c e s s a t i o n ( F i g . l l l ) .Of | | 2 smoking asthmatic patients 80 (7 | ,4 %) did not receive any antismoking advice from the doctor. Of 185 hypertensive patients l4l (76,2 7d indicated that they did not receive any antismoking advice from the doctor as did 109 (8,6 n of diabetic patients.
However 803 (94,5 7d patients indicated that they would return to their respective CHC for antismoking counselling should they decide to stop smoking.The record audit revealed that 64 | (714n of patients did not have their smoking status recorded in their folders (Fig.lV) and that 592 (69,6%) had a smoking-rrelated presenting complaint
Figure l:Smoking prevalence at community heolth centres in the CapeTown
metropolitan oreo
E L S I E R I V E R
H T I D E V E T D
H.PARK
LOTUSRIVER
M . P L A I N
RETREAT
A t t
40fo 50% 600/. Smoking Prevalence B0o/. 70to 307o 20o/"G
Figure I I: Percentoge
of patients who received ontismoking advice from the doctor
ETSIERIVER
H E I D E V E T D
H.PARK
TOTUSRIVER
M.PLAIN
RETREAT
A t L
0Io 10lo 20Yo 30T" 40to 50o/o 600/0 70"/o
Percentage of Patients
Figure II I: Percentage
of patients who rcceiyed antismoking odvice from the sister
ELSIERIVER
H E I D E V E T D
H.PARK
TOTUSRIVER
M . P t A I N
RETREAT
ALt
0o/o 10o/o 20o/o 30To 40o/o 50Yo 60o/" 70o/o
Percentage of Patients
Figure lY:Percentage of patients who had their smoking stotus recorded in the folder
E L S I E R I V E R
HEIDEVETD
H.PARK
TOTUSRIVER
M.PtAIN
RETREAT
A[L
OYo 10To 20Yo 30To 40To 50"/o 60Yo 70Yo Percentage of Patients g (J G U qr o T E I
D i s c u s s i o n
Although studies have shown that manypatients fail to recall information given by doctorsrs're and the proportion of patients who had actually received advice from the primary health care practitioner may thus have been much higher than indicated by the responses to the questionnaire, this study has s h o w n t h a t a h i g h p r o p o r t i o n o f potential opportunities for antismoking education are currently being missed in patients attending selected CHC in the Cape Town Metropolitan Area.
Primary Health Care is widely being a c k n o w l e d g e d a s b e i n g o f v i t a l i m p o r t a n c e i n h e a l t h p r o m o t i o n generally re and in smoking cessation in particular. With the overall smoking prevalence in CHC as high as 62,6 %, u r g e n t i n t e r v e n t i o n i s r e q u i r e d t o improve the situation.As more females a t t e n d C H C , 6 9 , 5 % o f t h i s s t u d y population,an important strategy would include targeting female patients who are at the centre of the family as a role model. Thus preventing women from starting to smoke can influence the health of her unborn child and children in the household.ln addition the younger age group, 15 to 44 years, constitutes the highest proportion of smoking patients (68,2%) and therefore should be targeted in an attempt to discourage them from starting to smoke.The vast majority (9 | ,6% ) of patients are aware of the harmful effects of smoking and 94,4%have also expressed a desire to stop.This could serve as a stimulus to initiate antismoking education during routine consultation where appropriate. ft is encouraging to note that84,2% of patients have attempted to stop smoking at least once although most of those who tried to stop had no suppoft. Some aspects of antismoking education at CHC described in this study are cause for concern,viz.the findings that: i . 6 9 , 6 % o f s m o k i n g p a t i e n t s
presented with smoking related problems;
ii. 56 % of smoking patients were never advised or assisted to stop smoking since they had started attending C H C f o r s m o k i n g r e l a t e d complaints;
76,7% of smoking patients were not advised against smoking on the day of their index visits;
81,9 % of patients indicated that t h e i r d o c t o r s d i d n o t m e n t i o n anything about smoking cessation during consultation;
75,4% of patients did not have their smoking status recorded in their folders;
vi. 57,8 % of patients stated that the primary health care sister did not advise them against smoking during a consultation;
v i i . 8 0 ( 7 1 , 4 % ) o u t o f I 1 2 s m o k i n g asthmatic patients did not receive a d v i c e a g a i n s t s m o k i n g o n t h e index visit.
D e s p i t e t h e s e c o n c e r n s 9 7 , 5 % o f patients feel that the doctor is the most appropriate person to assist them with s m o k i n g c e s s a t i o n a n d e x p e c t t h e doctor to be competent in doing so. lt is also encouraging to note that 803 (94,5%) patients indicated that they would return to their respective CHC for counselling should they decide to stop smoking.
Primary health care sisters seem to have performed better than the medical officers, but whether this difference is statistically significant has not been determined. The results suggest that antismoking activities do not regularly occur despite the longer time sisters have during consultations. Reasons for this performance may include pessimism about their patients' ability to quit; l i m i t a t i o n s in t h e i r o w n t r a i n i n g i n behavioural techniques;and as shown in this study a paucity of effective support materials. lf practice nurses are to use opportunities in primary care to help smokers, there is clearly a need to provide further training and to establish the effectiveness of nurses in their role
i l t .
as smoking educators. Little is known aboutthe attitudes and beliefs of practice n u r s e s a b o u t s m o k i n g a d v i c e , t h e smoking behaviours of practice nurses and whether this influences their advice to smokers or their specific needs for further training.20 Several studies 2r'22 have indicated that minimal advice and counselling about quitting given by primary health practitioners or nurses to patients on routine visits in the primary care setting are highly cost-effective 2a and are particularly successful, if the caregivers are adequately trained i n c e s s a t i o n c o u n s e l l i n g m e t h o d s .
2t,22,23,24,2s,26
Heahh education resources in antismoking education however were used surprisingly infrequently, suggesting a need for closer link between heahh education and primary health practitioners to ensure that bookles and leaflets are put into use.
Constantly changing staff, results in a disturbing number of different doctors consulted at each CHC.This leads to a lack of continuity of care and a poor doctor-patient relationship, which may increase missed opportunities. Due to the previous fragmentation of health centres in South Africa the CHC have until recently been involved in curative services only and it is probable that the medical and nursing staffdo not perceive prevention as falling within their sphere of responsibility.This may increase the probability of missing opportunities for preventative intervention. However, the recent trend towards a district health system should improve on the previous fragmented approach to health care and provide a rapid integration of preventive and curative components of health care into a metrooolitan based district health system.
A limitation of the study is the fact that it does not include Xhosa-speaking patiens, but it is hoped that this rcsearch may serve as a stimulus for more definitive work which would include a broader sDectrum of patients.
The main recommendation arising from this research is that all smoking patients should be routinely advised against smoking irrespective of what their presenting complaints are. Effective support and strategies for follow-up are required. Obtaining a smoking history and recording it prominently in the folder is a minimum step. This expression of interest alone may be sufficient to encourage some patients to change their habit.
C o m p l i a n c e o f p r i m a r y h e a l t h c a r e practitioners in recording the smoking s t a t u s o f t h e i r p a t i e n t s s h o u l d b e i m p r o v e d . D e s i g n i n g fo l d e r s w i t h prominence to smoking status as is
c u r r e n t l y g i v e n t o a l l e r g y a n d i m m u n i s a t i o n s t a t u s s h o u l d b e considered.Such an innovation might act a s a r e m i n d e r t o p r i m a r y h e a l t h practitioners of the important potential for health education,which exists in every consultation. Antismoking advice is not only free, simple, and practical, but should be given routinely as it has been shown in controlled trials to be cost-effective. Patients are also more likely to stop smoking if they receive antismoking messages in a variety of forms and from a number of sources. In addition to giving tailored individual advice, high-risk groups s u c h a s p o t e n t i a l s m o k e r s ( y o u n g s c h o l a r s ) , f e m a l e s a n d t h o s e w i t h additional riskfactors should be targeted.
The potentiallygr.eater benefits of changing lifestyle (i.e. smoking cessation) when mukiple risk hctors of IHD are preseng2T need to be more widely dissem-inated. Lifestyle modification (in partlcuhr smoking cessation programmes) is not only a questlon of infl uencing and persuading the general public, but the mobilisation of primary health care professionals to support this endeavour may present another challenge. lt is hoped that these f i n d i n g s w i l l c o n t r i b u t e t o t h e implementation of change and increased ' avrarcness of tobacco smokingas the most imponant cause of preventable disease and premature mortality in developed countries.
Community Health Centres for their co-operation and assistance. The Medical S u p e r i n t e n d e n t s f o r p e r m i s s i o n t o perform research at the Community Health Centres. Financial assistance from the University of Stellenbosch; The Harry Crossley Foundation.
d g e m e n t s
The authors would like to thank the
following
people
for their contributions:
Dr. Kenith
Landers
and Dr:JimmyVolmin(
for comments
on the protocol, Mrs.
Patricia
Pather
for typing
the manuscript
Mr^,V
McPherson;
Mrs, C. McPherson,
Mr.A. Pather, Mr. H.Van der Merwe, Mr. G. Kiewit - for doing the fieldwork. Dr. C. Bezuidenhout for conducting the record auditing. Mr. Roelf Sayed - for valuable assistance with Epi6 and the statistical analysis. Doctors in charge and r e c e p t i o n i s t s o f t h e p a r t i c i p a t i n g
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