title: Understanding implementation and feasibility of tobacco cessation in routine primary care in Nepal: a mixed methods study.
abstract: BACKGROUND
  By 2030, 80 % of the annual 8.3 million deaths attributable to tobacco will be in low-income countries (LICs). Yet, services to support people to quit tobacco are not part of routine primary care in LICs. This study explored the challenges to implementing a behavioural support (BS) intervention to promote tobacco cessation within primary care in Nepal.
  
  
  METHODS
  The study used qualitative and quantitative methods within an action research approach in three primary health care centres (PHCCs) in two districts of Nepal. Before implementation, 21 patient interviews and two focus groups with health workers informed intervention design. Over a 6-month period, two researchers facilitated action research meetings with staff and observed implementation, recording the process and their reflections in diaries. Patients were followed up 3 months after BS to determine tobacco use (verified biochemically) and gain feedback on the intervention. A further five interviews with managers provided reflections on the process. The qualitative analysis used Normalisation Process Theory (NPT) to understand implementation.
  
  
  RESULTS
  Only 2 % of out-patient appointments identified the patient as a smoker. Qualitative findings highlight patients' unwillingness to admit their smoking status and limited motivation among health workers to offer the intervention. Patient-centred skills needed for BS were new to staff, who found them challenging particularly with low-literacy patients (skill set workability). Heath workers saw cessation advice and BS as an addition to their existing workload (relational integration). While there was strong policy buy-in, operationalising this through reporting and supervision was limited (contextual integration). Of the 44 patients receiving the intervention, 27 were successfully followed up after 3 months; 37 % of these had quit (verified biochemically).
  
  
  CONCLUSIONS
  Traditionally, primary health care in LICs has focused on acute care; with increasing recognition of the need for lifestyle change, health workers must develop new skills and relationships with patients. Appropriate and regular recording, reporting, supervision and clear leadership are needed if health workers are to take responsibility for smoking cessation. The consistent implementation of these health system activities is a requirement if cessation services are to be normalised within routine primary care.
authors.affiliation: Nuffield Centre for International Health and Development (NCIHD), University of Leeds, Room G.22, Charles Thackrah Building, 101 Clarendon Road, Leeds, LS2 9LJ, UK. h.elsey@leeds.ac.uk.
authors.forename: Helen
authors.identifier: http://orcid.org/0000-0003-4724-0581
authors.initials: H
authors.lastname: Elsey
authors.affiliation: Health Research and Social Development Forum (HERD) Nepal, Thapathali, POBox: 24133, Kathmandu, Nepal.
authors.forename: Sudeepa
authors.initials: S
authors.lastname: Khanal
authors.affiliation: Health Research and Social Development Forum (HERD) Nepal, Thapathali, POBox: 24133, Kathmandu, Nepal.
authors.forename: Shraddha
authors.initials: S
authors.lastname: Manandhar
authors.affiliation: Health Research and Social Development Forum (HERD) Nepal, Thapathali, POBox: 24133, Kathmandu, Nepal.
authors.forename: Dilip
authors.initials: D
authors.lastname: Sah
authors.affiliation: Health Research and Social Development Forum (HERD) Nepal, Thapathali, POBox: 24133, Kathmandu, Nepal.
authors.forename: Sushil Chandra
authors.initials: SC
authors.lastname: Baral
authors.affiliation: Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York, YO10 5DD, UK.
authors.forename: Kamran
authors.initials: K
authors.lastname: Siddiqi
authors.affiliation: Nuffield Centre for International Health and Development (NCIHD), University of Leeds, Room G.22, Charles Thackrah Building, 101 Clarendon Road, Leeds, LS2 9LJ, UK.
authors.forename: James Nicholas
authors.initials: JN
authors.lastname: Newell
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005069:Evaluation Studies as Topic; D005240:Feasibility Studies; D005260:Female; D017144:Focus Groups; D005500:Follow-Up Studies; D006284:Health Plan Implementation / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009390:Nepal; D011320:Primary Health Care / Q000379:methods*; D020340:Tobacco Use Cessation / Q000379:methods*; D014029:Tobacco Use Disorder / Q000628:therapy*
keywords: Implementation; Nepal; Primary care; Smoking; Tobacco cessation