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Global BridgesPre-conference Workshop

Dr Lekan Ayo-Yusuf, DDS, MPH, PhD

African Region

SRNT preconference Meeting, Boston

March 13, 2013

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OBJECTIVE 3

To facilitate the implementation of Article 14 in every nation

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Develop national cessation guidelines

Article 14 states, “Each Party shall develop and disseminate appropriate, comprehensive and integrated guidelines based on scientific evidence and best practices, taking into account national circumstances and priorities, and shall take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence”.

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Provision of the WHO FCTC Article 14

1. People – HPCs, traditional healers, community workers

2. Place – clinics, hospitals, schools and community centres

3. Practice: Brief advice and counselling for individuals Need: country-specific clinical guidelines (0%)Promote cessation – Integrate with other articles (synergism with e.g. 6, 8,11,12,13) - TC currently low level implementation

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The focus of Article 14 is to (1) encourage more people to make attempts to cease tobacco use and (2) utilise effective interventions  to  make the success of these attempts more likely

The priority for countries with low levels of tobacco control is to implement effective strategies to promote cessation and then to later provide TDT, starting with broad reach low cost interventions that, as far as possible, use existing infra-structure

Countries with an existing and strong tobacco control framework should •Focus on achieving full coverage of the basic approaches (e.g. brief advice to quit) within their healthcare systems and monitoring the impact of these•Work to improve the impact of TDT by ensuring greater reach and efficacy

A14 guideline: Stepwise approach

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Use opportunities for tobacco cessationProgrammes and settings to

promote tobacco cessation Media campaigns and local events

such as World No Tobacco Day (WNTD) activities (64% of 28 surveyed countries in 2011).

Quit-line (currently 1)– promote introduction of free services in Africa (leverage on mobile phones).

Integration of cessation services into various levels of the health-care systems and other articles (Hospitals & addiction services - ASSIST).

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Supporting demand reduction measures

Gambia & Togo to introduce a new tobacco taxation policy in January 2013

Congo’s Parliament adopted in July 2012 legislation containing provisions banning smoking in public places and the sales of tobacco products to minors, forbidding tobacco advertising, promotion and sponsorship, and calling for health warnings on tobacco packages

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Demand reduction measures (cont..) Senegal & Mauritius ran

campaign on effects of SHS to promote cessation (by WLF).

The Cameroon Coalition Against Tobacco in association with the regional WHO office, held a training for CSOs and members of the Public Administration on the implementation of WHO FCTC and issues of non-Communicable Diseases resulting from tobacco use.

Promote treatment as part of NCD control in partnership with CSO

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Integrative treatment for

tobacco use and dependence

PUBLIC AWARENESS POLICY SUPPORT

COUNSELLING

(start Brief advice)

MEDICATION

QUIT LINEAccessible

Affordable

Evidence-based

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OBJECTIVE 2

To provide state-of-the-art, evidence-based training in treatment and advocacy to network members

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Need to understand effect of policy synergies

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Prevalence of Current Programs

Countries respondingto survey (5 Afro countries)

Countries with a currentprogram

All C

ou

ntr

ies

Hig

h

Incom

eC

ou

ntr

ies

Mid

dle

In

com

eC

ou

ntr

ies

Low

In

com

eC

ou

ntr

ies

Afr

ican

Am

eri

cas

Easte

rnM

ed

iterr

an

ean

Sou

th E

ast

Asia

Weste

rnP

acifi

c

Eu

rop

ean

Income Level Geographic Region

Rigotti NA, Bitton A, et al. An international survey of training programmes for treating tobacco dependence. Addiction 2009 Feb;104(2):288-96.

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How Many People are Trained Each Year?

14,194 trained in 2007–5374 Americas–3759 Europe–3131 Western Pacific–1760 Southeast Asia– 98 Eastern Mediterranean– 72 Africa

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Why train healthcare professionals in MI

Motivational interviewing is one of the most cost-effective interventions in medicine

Key message = smoking is dangerous and it is worthwhile stopping

Motivate patient attempts at smoking cessation

Aimed at individual smokers and should be used by all health care professionals opportunistically

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Curriculum

Health effects of tobacco use Local and global (WHO FCTC) policy

initiatives for tobacco control Basics of nicotine dependence and

pharmacotherapy Basics of behavioural therapy for

tobacco use cessation Elements and principles of brief

Motivational Interviewing and strategies to elicit and respond to “change talk”

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Training in treatment and advocacy

Training follows level two of ATTUD provider proficiency and MI as the behavioural support strategy over 3 days–Day 1 - didactic teaching to provide knowledge, –Day 2 (one half of the group) and Day 3 (other half) - application of ‘skills’ through practice/role-play activities. Ends with a discussion on challenges and solutions to implementing what they have learned.

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Training in treatment and advocacy (cont.)

20-24 participants (MDs, nurses, dentists, counselors, physiotherapists, lay counsellors (doing HIV test counselling) etc.)

2-day trainings held: Nigeria (3 states), South Africa, Zambia, DRC, Uganda and Mauritius = 468 trainees

Future trainings: Tanzania, Ghana, Lesotho and South Africa

Also conduct a one-day programme for a larger audience at pre-conferences

–competency outcome of level one of ATTUD framework

South Africa (2 provinces), Ethiopia Upcoming: South Africa (Cape Town)

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Qualitative Results

Top-expectation of workshop:–To learn about MI–Smoking behaviour and Dx burden

What they liked most:–Role-plays

What they liked least:–Limited time to practice MI

Pre-course

Post-course

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Evaluation of training

Table 1: Changes in confidence levels to deliver MI following training

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6-months post training reports

Knowledge and skill transfer among peers through seminars, lecturing and publications in newsletters

Some developed proposals for tobacco cessation clinics and initiated projects

–Requests for financial assistance from GB: E.g. in DRC, they drafted a proposal for the integration of tobacco dependence treatment in Kitambo health zone in Kinshasa and would like to train HCPs–MoH would then replicate service

Most trainees reported that the knowledge and skills have improved their understanding of tobacco control issues and MI skills

Implementation challenges include not having enough time to effectively integrate MI in routine treatment, non-disclosure of smoking status by patients and lack of institutional support

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OBJECTIVE 1

To create and mobilize a global network of HCPs and organizations dedicated to advancing effective tobacco dependence treatment and advocating for effective tobacco control policy

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GB African Regional network – Countries represented:~50% of

the population

Africa

Morocco

Algeria

Angola

Benin

Botswana

BurkinaFaso

Burundi

Cameroon

CapeVerde

Central AfricanRepublic

Chad

Comoros

Djibouti

Egypt

EquatorialGuinea

Eritrea

Ethiopia

Gabon

The GambiaGhana

Guinea

Guinea-Bissau

Kenya

Lesotho

Liberia

Libya

Madagascar

Malawi

MaliMauritania

Mauritius

Mozambique

Namibia

Niger

Nigeria

Rwanda

São Toméand Príncipe

Senegal

Sierra Leone

Somalia

SouthAfrica

Sudan

Swaziland

Tanzania

Togo

Tunisia

Uganda

Zambia

Zimbabwe

DR Congo

Congo

Côted'Ivoire

<10%

10-19%

>=20%

No DataSeychelles

Prevalence estimates

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Conclusions The policy environment and the PHC systems

intervention, including quitline infrastructure in LMICs needs scaling up (<30% have basic Rx infrastructure).

We may need systems change at PHC to increase demand and take advantage of economies of scale in introducing medications at reduced cost e.g. EDL

Prioritize training medical students in treatment & raise awareness & training of other community health workers.