This study found that participants perceive the implementation of TDT to be an important and beneficial task, and that HCPs’ behaviours result from their perceptions of their roles in implementing TDT, their knowledge and counselling skills (or lack of such skills), misperceptions and misconceptions about the effectiveness and feasibility of TDT during the consultation, and several limitations imposed by the health system (time constraints arising from an excessive patient load, a lack of continuity of care and the unavailability of cessation treatment modalities). While similar findings have previously been reported in studies conducted elsewhere [8, 15–17], this study provides the first in-depth understanding of HCPs’ behaviours in South African PHC and suggests a need for multipronged interventions to improve the implementation of TDT.
HCPs’ perceived role(s) and selective screening behaviours
Participants recognized and accepted their role(s) in assisting tobacco users to cease tobacco use, but time constraints imposed by high patient loads were probably responsible for their opting for selective screening and for counselling based on clinical relevance. HCPs may attempt to maximize the impact of TDT by focusing only on patients with diseases perceived to be tobacco-related [18, 19]. Nonetheless, the HCPs did not always perceive tobacco use as a health problem, except when it is associated with a disease state. Patients who do not present with physical ailments are therefore not likely to be screened. Such selective screening behaviours result in missed opportunities for TDT, which can be addressed by adopting tobacco use status as a vital sign. This has been shown to improve screening, counselling and referral rates [20–22].
In South Africa, physicians and PHC-trained nurses render clinical services. Although both cadres of HCPs accepted responsibility for implementing TDT in this study, in the South African PHC context, physicians take on more complex patients compared to PHC nurses, and, in the context of heavy patient loads, this may result in doctors’ relegating their counselling role to nurses. Nurses are therefore perceived to “do a lot of counselling”. However, physicians have also been known to delegate such tasks in the belief that smoking cessation assistance may be best provided by other categories of HCPs . The latter may be the more likely explanation for physicians’ failure to provide TDT in this study, given that most physicians’ perceived themselves as not knowledgeable and as having low self-efficacy with regard to TDT.
Misperceptions, misconceptions and poor knowledge of the cessation process
HCPs’ behaviours are influenced by several misperceptions and misconceptions. Misperceptions that HCPs should only “…give the information and leave it, because they are adults, they know what to do.....and we cannot force it on them”, and that it is the patient’s prerogative to stop smoking may signify HCPs’ lack of knowledge and understanding of the entire TDT process. Not understanding nicotine addiction and the process of cessation could result in prejudices, negative attitudes and missed opportunities, with the result that patients who need additional interventions beyond offering advice are not assisted. It is known that most tobacco users want to quit , but chemical dependence and withdrawal symptoms make it an uphill task , indicating that most tobacco users will require support in some form for a successful outcome. Considering that patients do not always make a change to less risky behaviours at one go (even in the face of a serious diagnosis) , HCPs need to recognize their duty to motivate tobacco users to quit and to continue to provide support to patients during the process of changing undesirable health behaviours . This is especially important in South Africa, where reports suggest that doctors do not take responsibility for, nor intervene in, their patients’ tobacco use habits .
Despite evidence that behavioural therapy alone, including brief advice provided by an HCP are effective in promoting tobacco use cessation [6, 27], participants in this study reported that counselling is not effective on its own, except when combined with cessation drugs. This misconception may reflect one or more of three issues: HCPs’ lack of awareness and understanding of the effectiveness of counselling as a stand-alone intervention, their negative outcome expectation of tobacco cessation counselling, or their perceptions of low self-efficacy in providing TDT [8, 28]. These misconceptions create an inertia that hinders the use of brief advice and varying levels of counselling intensity as effective interventions, and signify an urgent need for training. Although tobacco cessation drugs facilitate cessation , they should not preclude counselling. Moreover, considering that most South African smokers are light smokers , they can be assisted to quit with appropriate counselling and behavioural support.
Participants’ poor awareness of the 5As framework or any other evidence-based approach is a reflection of their lack of knowledge and skills, and may explain their perceived low self-efficacy in TDT. Saloojee and Steyn , explain that the reluctance of doctors to act and assist tobacco users points to a lack of skills and competence . A similar reflection of lack of knowledge is the fact that the participants in the current study focused mostly on the adverse health effects of smoking and did not report the health implications of snuff use, second-hand smoke and other forms of tobacco use, though these are also associated with significant morbidity and mortality [30, 31]. Therefore HCPs need to be trained on the health implications of all forms of tobacco use and on the need to screen for them, including screening for other addictions, given that concurrent addictions decrease the likelihood of successful quit attempts [29, 32]. Training has been shown to increase providers’ knowledge and confidence, as well as the likelihood and the extent of implementing tobacco cessation interventions [17, 20, 33–36]. In order to address this knowledge gap through training, Saloojee and Steyn , suggest that for HCPs to recognize and take advantage of the opportunities provided by the clinical encounter, changes in medical school training are required . Their proposal will equip health professions students to prepare for clinical work, but currently practising HCPs who are products of deficient curricula will also require structured and ongoing in-service training to improve their competence in TDT.
Counselling is effective as a tool for effecting behavioural change . However, African cultural views such as that expressed by one participant (P10; Physician, >5 years’ experience) on how people of different ages should relate could pose a challenge to counselling against tobacco use. The view that young HCPs may be seen as disrespectful when they try to motivate older patients to quit tobacco use implies that HCPs should be culture-sensitive in their approach to tobacco cessation counselling [26, 37]. Similarly, although there is no evidence to suggest this is a systemic problem, the difficulties experienced by some HCPs and patients regarding different races in the giving and receiving of health advice may indicate remnant historical prejudices in post-apartheid South Africa, and calls for a response that does not constitute further barriers to implementing TDT during a clinical encounter.
The need for system changes
Several of the participants’ perceptions highlight a need for changes in the way TDT is currently implemented. Suggested changes are discussed below.
Firstly, in order to minimize missed opportunities for tobacco prevention, tobacco use status needs to be adopted as a vital sign. This would ensure that all patients are screened. Indeed, maximizing the impact of TDT requires HCPs to screen all patients and provide treatment support to all tobacco users . This may not be always feasible in a setting where there are extreme time constraints, but providing treatment opportunities, particularly referral support networks to which tobacco users can be referred may result in more quit attempts and higher quit rates . Such support networks should also be used as points of contact for follow-up in order to address the reported lack of continuity of care. Surprisingly, most participants were not aware of the existing national quit line, which reveals the need to integrate quit lines formally into health services in South Africa.
Secondly, most HCPs lack knowledge, are poorly skilled, and have misconceptions and misperceptions about TDT. This indicates an urgent need for HCPs to be trained on TDT. Such training should aim to provide information that dispels myths, misconceptions and misperceptions, and should also be leveraged on the fact that the majority of HCPs do not use tobacco themselves to promote the implementation of TDT by them, as this cohort is more likely to engage in TDT .
Thirdly, there is abundant evidence of the effectiveness of tobacco cessation medications . Many tobacco users will quit with counselling and behavioural support, and the addition of cessation medications to counselling when indicated is likely to increase the odds of successful cessation . There is therefore a need to incorporate them into the Essential Drug List at the PHC level in South Africa.
Fourthly, the perception that tobacco control is not a priority on the government’s agenda may explain participants’ experiences of a lack of organizational support for tobacco cessation treatment in their own setting. Considering that tobacco use is an important risk factor for morbidity and premature mortality in South Africa , TDT in the clinical setting needs to be prioritized on an equal footing with other health programmes such HIV/AIDS and TB programmes, in line with the government’s commitment to the recent United Nations declaration on the eradication of non-communicable diseases .
Fifthly, participants’ recommendation that anti-tobacco campaigns be expanded to community organizations using multimedia may be informed by a perceived need for an expanded and innovative anti-tobacco campaign platform. Such innovative approaches to anti-tobacco campaigns that take advantage of developments in information technology and advertisement media can extend the reach of anti-tobacco campaigns. Admittedly, while innovative campaigns may be well received especially by the young, the evidence that they increase cessation rates remains inconclusive .
Lastly, the view that tobacco diverts money from essential materials of life and the suggestion that HCPs need to explore the socioeconomic effects of tobacco use have been confirmed in reports that found that tobacco use is a “financial drain” and is associated with poverty . Given that poor people are most sensitive to the price effects of tobacco, future studies need to explore the cost implications and socioeconomic patterning of tobacco, including the economic gains of tobacco control in South Africa.
Explaining HCPs’ screening and counselling behaviours using the social-cognitive theory
An explanatory model (Figure 1) based on social cognitive theory was developed to explain the interconnectivity of themes identified in this study. The social cognitive theory explains how behaviours are acquired and maintained, and proposes that behaviour change result from continuous interactions between cognitive, personal and environmental factors . These factors have varying strengths in interactions and do not necessarily occur concurrently .
In this study, it is proposed that the participating HCPs’ behaviours resulted from continuous interactions between environmental and socio-cultural factors (healthcare system demands and constraints, and patient characteristics), personal cognitive factors (poor outcome expectations of HCPs' behaviours, misperceptions and misconceptions regarding the effectiveness and feasibility of TDT, HCPs’ lack of adequate knowledge and skills) and perceptions of low self-efficacy in offering TDT). These complex interactions inform HCPs’ decisions not to screen all patients, but to selectively screen patients with tobacco-related diseases.
HCPs’ tobacco use screening and treatment behaviours are indeed influenced by the demands and limitations imposed by local healthcare and social systems. The demand to implement TDT is exemplified in perceptions that it is important to implement TDT to improve the health status of patients and that it is an HCPs’ responsibility to implement TDT. On the other hand, perceptions that tobacco control is not a priority on the government’s agenda, perception that TDT is not feasible within consultations happening under pressure in overcrowded clinics, a lack of treatment and referral support, the unavailability of cessation medications and negative cultural views, all limit full implementation of TDT.
HCPs’ perception and misconceptions about their own self-efficacy and the effectiveness and feasibility of TDT also interact with other factors to determine HCPs’ behaviours. For example, most HCPs have not been trained in, and therefore lack knowledge and awareness of, any evidence-based tobacco treatment framework, which in turn results in poor counselling skills and low self-efficacy. Given an environment characterised by high patient loads and no referral support, HCPs hold a perception that “much can’t be done”. In addition, there are perceptions that counselling is not effective on its own, that it needs to be combined with medications, and there is an outcome expectation that patients may not change their behaviours even when counselled – all this results in most HCPs not screening and advising tobacco users to quit.
Participants recommended several system changes aimed at changing HCPs’ behaviours. In the proposed model, if the government were to prioritize tobacco control in a clinical setting, then training of HCPs would become a priority. Training can boost HCPs’ self-efficacy, which in turn alters HCPs’ outcome expectations so that HCPs may perceive it to be possible for tobacco users to change their behaviours when they are helped. Establishing referral support centres and quit lines to which tobacco users can be referred (or making HCPs aware of existing structures of this nature) can also alter HCPs’ current outcome expectations of the feasibility of TDT within the clinical consultation to a favourable one. These changes in outcome expectations can in turn promote screening of all patients and the provision of TDT. Adding cessation drugs to the Essential Drug List may increase HCPs’ confidence in their ability to intervene, knowing that if tobacco users fail to quit with counselling, cessation medications can be added, a practice which has been shown to be more effective than counselling alone . Implementing these recommendations could alter this triadic model and favourably change HCPs’ behaviour to increase screening and offering comprehensive TDT.
This study used a qualitative design and the findings may therefore not be generalized. The study was also based on participants’ self-reports, making the findings susceptible to information bias. The position of two of the researchers (senior clinicians) in the research setting could have unduly influenced the responses of the participants. However, self-awareness of the researchers, the use of facility managers as recruiters, the use of a trained research assistant for the interviews and the methodological rigour employed in assuring credibility and trustworthiness, all assisted in limiting potential undue influences and biases.