FINAL PROPOSAL TO GLOBAL BRIDGES A. Project …...Final proposal from the IPCRG (Project ID: 25678413) 3 C. Reviewer Comments None received. D. Main Section of the proposal (not to

FinalproposalfromtheIPCRG(ProjectID:25678413)

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FINALPROPOSALTOGLOBALBRIDGES

A. Titlepage

ProjectID: 25678413

Projecttitle: Category1:CapacityBuilding-Teachingtheteachersofprimaryhealthcareprofessionalstotreattobaccodependence

Organisation:InternationalPrimaryCareRespiratoryGroup

Maincollaborators:

• BulgarianGeneralPracticeSocietyforResearchandEducation• Centre for Family Medicine, Medical Faculty, University Ss Cyril and Methodius,

Skopje• KyrgyzThoracicSociety• RespiRo(NationalCentreforStudiesinFamilyMedicineandtheNationalSocietyof

FamilyDoctors)

Abstract:

The project goal is to develop a sustainable network of teachers who will increase thecapacityofhealthcareprofessionalsworkinginprimarycaretotreattobaccodependenceinfour countries: Romania, Bulgaria, the Republic of Macedonia and the Kyrgyz Republic.These four countries in the WHO European Region have high rates of smoking andexperience similar challenges in the provision of evidence-based treatment for tobaccodependence. The World Health Organization has called for smoking cessation to beintegrated into primary healthcare globally. This requires primary care professionals havethe capacity, opportunity andmotivation to provide treatment and are able to prescribepharmacotherapythatisaffordabletopatients.However,inthefourparticipatingcountries,evidenceshowsprovisionoftreatmentandaccesstopharmacotherapyislow.

Over two years the project will equip 1,000 primary healthcare professionals with theknowledgeandskills to treat tobaccodependenceconfidently in theircommunity,usingacascading “Teach the Teachers” model, developed and used successfully by IPCRG.ParticipantswillberecruitedbyIPCRG’spartnerorganisationsineachofthefourcountriesthat are established providers of continuing medical education (CME). These primaryhealthcareprofessionalswillseemorethan165,000patientswhoarecurrentsmokerseveryyear. Theprojectwill contributetoan increase inquitattemptsand improvingaccess topharmacotherapyby increasingknowledgeofanddemandfor it. Itwillalsocontributetospreadingandsustainingeducationontreatment for tobaccodependencebyensuringthemodulesitdevelopsarerecognisedbyCMEproviders.


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B. TableofContents

A. Titlepage 1

B. TableofContents 2

C. ReviewerComments 3

D. MainSectionoftheproposal(nottoexceed15pages) 3

1 OverallGoal&Objectives 3

2 CurrentAssessmentofneedintargetarea 4

3 TargetAudience 8

4 ProjectDesignandMethods 11

5 EvaluationDesign 13

6 DetailedWorkplanandDeliverablesSchedule 14

E. References 17

F. OrganizationalDetail(nottoexceed3pages) 19

1 OrganizationalCapability 19

2 Leadershipandstaffcapacity 21

G. DetailedBudget 22

H. StaffBiosketches 23

I. Letter(s)ofCommitment(1pagelimitperletter): 32


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C. ReviewerComments

Nonereceived.

D. MainSectionoftheproposal(nottoexceed15pages)

1 OverallGoal&Objectives

Thegoal is todevelopasustainablenetworkof teacherswhowill increasethecapacityofhealthcare professionals working in primary care to treat tobacco dependence1in fourcountries:Romania,Bulgaria,theRepublicofMacedoniaandtheKyrgyzRepublic.

This goal aligns with the Request for Proposals (RFP) focus as it includes four countrieswithintheWHOEuropeanRegionandsupports theGlobalBridgesapproachtopromotingcollaboration across multiple countries. The project will build capacity, which includescapability,motivationandopportunity,forprimaryhealthcareprofessionalstotreattobaccodependence, using the approach outlined in the International Primary Care RespiratoryGroup’s (IPCRG) Education Strategy.1 This approach stresses that education programmesmustengagehealthprofessionalsintheirlearning,provideongoingsupportandbesensitiveto local circumstances. The project will extend a successful IPCRG ‘Teach the Teacher’initiative,andwillalsoadaptexistingIPCRGeducationalandclinicalresourcestotheneedsofnewcontextsandaudiences.

The project alignswith the IPCRG’s aim to support primary care professionals to providebetterqualityrespiratorydiagnoses,treatmentandcare.Italsoalignswiththeaimsofourfour collaborating national organisations who will deliver the project activities in eachcountry as these organisations are providers of continuingmedical education (CME)withtheirmembersinprimarycare.

Theobjectivesoftheprojectare:

1. To teach and develop a sustainable network of primary care teachers from fourcountries, skilled in the management of tobacco dependence and to assist them todevelopsystemsthatbestsupportimplementationinroutinepractice

2. Tosupporttheseteachersindevelopingandimplementingcountrybasedprogrammestospreadthisknowledgeintheon-goingeducationofprimaryhealthcareprofessionals,includingthedevelopmentofdistancelearningresources.

3. Toadaptexistingresourcesonthetreatmentoftobaccodependencetothelocalcontextsinthesefourcountries.

4. Toincreasethecapacityofarangeofprimaryhealthcareprofessionals,includingGPs,nursesandcommunitypharmacists,intreatingtobaccodependence.

5. Toimprovethehealthoutcomesofpatientswithtobaccodependenceseeninprimarycarebyincreasingthenumberofquitattemptsandthenumberofsuccessfulquits.

1Throughoutthisproposalweusethephrase“tobaccodependence”.Theprojectwillbeparticularlyfocusedon cigarette dependence as this is by far the most widespread means of tobacco consumption in theparticipatingcountries.


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Theseobjectivesmeettheneedestablishedinresearch literatureforsmokingcessationtobe integrated intoprimaryhealthcareby improvingand increasingthecapacityofprimaryhealthcareprofessionalstoprovideadviceandsupportforsmokingcessation.ItdoessoinfourEuropeancountriesthathavebeenidentifiedasfacingparticularchallenges,asoutlinedinthefollowingsection.Primaryhealthcareisprovidedbyfamilyphysicians(FPs)whohaveundertakenvocationaltraininginprimarycareandgeneralpractitioners(GPs)whohavenotundertaken vocational training. GPs, FPs and other professionals including medicalassistants, nurses and community pharmacists who play a key role in delivering primaryhealthcarearetheaudiencefortheproject.Thebeneficiariesarethepatientswithtobaccodependencetheyseeinregularprimarycareconsultations.

2 CurrentAssessmentofneedintargetarea

TheWorldHealthOrganization(WHO)hascalledforsmokingcessationtobeintegratedintoprimary healthcare globally, as it is the most suitable health system 'environment' forprovidingadviceandsupportonsmokingcessation.2 Helpingsmokersquitisoneofthemostcost-effective interventions available to clinicians. 3 Success rates are low for unaidedattemptstoquit.4Largenumbersofpatientsareseenwithinprimarycareandprimarycareprofessionals have on-going relationships with their patients. Primary health careencountersrepresentfrequentandimportantopportunitiestohelppeoplequitbecauseitisthe most prevalent chronic condition, and a risk factor for so many non-communicablediseases.5Researchhasshownthataround90%ofsmokersusedprimarycareatleastonceina12-monthperiod.6

Primary care professionals can provide ‘Very Brief Advice’ (VBA) to all attending patientswho smoke using a “make every contact count” approach. This ismost effectivewhen itincludesclear,strongandpersonalisedadvicetoquitfromhealthcarepractitionersaspartofgeneralmedicalcarewhichprimarycareprofessionalsarewellplacedtodeliver.Advicefromhealthprofessionals,whoaregenerallyhighlyrespected,abouttherisksoftobaccouseand the benefits of cessation are usually well received. Pharmacological treatment oftobaccodependencecandoublethelikelihoodthatsomeonewillsuccessfullyquit,andthislikelihood increases further if the medication is administered in conjunction withbehaviouralsupport.7,8

This approach requires that primary care professionals aremotivated to provide smokingcessationadviceandtreatmentandhavethecapacity,capabilityandopportunitytodoso.Itisalsorequiresthattheyareabletoprescribepharmacotherapyfornicotineaddiction,areknowledgeableabout themedicationsandcan supportpatientswith theiruseof them. Italso requires that this medication is affordable to patients. This in turn requires thatpharmacotherapy for tobacco dependence is licensed, available and subsidised and/orreimbursable as part of public financing systems for prescribed medications so it isaccessibleandaffordableforpatients.

However, there is a well documented ‘practice gap’ in the implementation of smokingcessation support by practitioners in routine clinical settings. International studies havedocumentedthatonlybetween40%and70%ofsmokersreporthavingbeentoldtoquitbypractitionersandfewerthan20%ofpractitionersprovidespecificassistancewithquitting,suchasbehaviouralsupportandmedications.9Thispracticegapisparticularlypronouncedinthefourcountrieswheretheproposedprojectwillwork:Romania,Bulgaria,theRepublicofMacedonia and the Kyrgyz Republic. In each of these countries recognition of primary


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care and familymedicine as a specialism is relatively newand consequently the status ofprimarycaretendstobe lowerthaninmoredevelopedspecialties. Inaddition,healthcaresystemsarerelativelyhierarchicalandunder-financed.10Romania,BulgariaandtheRepublicofMacedoniaarecategorizedasupper-middleincomecountriesandtheKyrgyzRepublicasalower-middleincomecountry.

In Macedonia specialisation in family medicine started in 2010 and in 2011 a retrainingprogrammeforexistinggeneralpractitionerswasdeveloped.Sofararound260doctorshavecompletedthisadditionaltraininginfamilymedicine(20%ofprimarycarepractitioners).InBulgariaprimaryhealthcareisprovidedinindividualorgroupmedicalpractices,witharound40%ofGPsbeingspecialistsinfamilymedicine.InRomaniageneralpracticebecameknownas familymedicine in1999withamajorreformof theprimaryhealthcaresystem.At thistimetheyceasedtobestateemployees, functioning insteadas independentpractitioners,contracted by the public health insurance fund but privately operating their medicaloffices. 11 In the Kyrgyz Republic 80% of patients attend primary healthcare, which isprovided by family physicians trained in a national post-graduate vocational scheme,medicalassistantsandnurses.

In all four countries, evidence indicates that motivation, opportunity and capability forprimarycareprofessionalstoprovideadviceandsupportonsmokingcessationremainslow.Akeyfactoristhesmokinghabitsofthedoctors.InMacedoniaasurveycarriedoutin2014about the attitude of medical doctors towards smoking found declining prevalence ofsmoking amongst doctors over the past decade from42% to 29%.12 However, based oninternational comparisons this remains high.13Anecdotal information from Romania, theKyrgyzRepublicandBulgariasuggestssimilarlyhighratesofprevalenceofsmokingamongstdoctorsinthesecountries.Thisisimportantbothbecausedoctorsareseenaspublichealthexemplars and because their own smoking reduces themotivation of doctors to providesupport to quit to their patients. It is also amarker of knowledge deficits of the harmfuleffectsof smoking. The same survey inMacedoniaalso found thatmore than46% statedthatduringtheireducationtheydidnotlearnabouttheneedtouseeducationalmaterialstohelp patients quit smoking and 19% responded negatively to the question "Do healthworkersneedtoadvisepatientswhosmokecigarettestoquit?".14

Although there has been little investment to date in increasing capacity of primary careprofessionals to treat tobacco dependence in these four countries, resources formedicaleducationforprimarycareprofessionalsandtheinfrastructurefordeliveringthesearenowbeing developed. There is also a growing awareness of and willingness to participate inmedical education initiatives. This offers an opportunity to ensure the need to developcapacity and capability on treating tobaccodependence is included in ContinuingMedicalEducation (CME) for primary care professionals in these four countries. This project isdesignedtousethisopportunitytofulladvantage.


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AGPusingacarbonmonoxidebreathmonitortodeterminesmokingstatusatarecent

IPCRGworkshop

Low cost pharmacotherapy has been shown to be effective, including cytisine which isactually produced in Bulgaria. 15 , 16 However, access to pharmacotherapy for nicotineaddictionineachofthefourcountriesislimited,whichisafactorcontributingtotheneedidentifiedbytheproject.InMacedonianicotinereplacementtherapy(NRT)isavailableinapharmacywithoutaprescriptionbutthenationalhealthinsurancefunddoesnotcoverthecost of this product because NRT is not on the country's essential drugs list. Othertreatment, including bupropion and varenicline, cannot be legally purchased in thecountry.17InRomaniaNRT isgenerallyavailable inurbanpharmaciesbut isexpensiveandnot subsidised. 18 Bupropion and varenicline are available but are not subsidised.Interventions tendtobe limitedtobriefadvice forpatientswithadiagnosedconcomitantchronicdisease,19andfewfamilyphysiciansreferpatientstosmokingcessationspecialists.12InBulgariadoctors inprimary carearenotpermitted toprescribemedication for tobaccodependenceanditisnotreimbursedbytheNationalHealthInsuranceFund.IntheKyrgyzRepublic smoking cessation treatment and support is not available in primary healthcare.ThereisonlyonespecialisedsmokingcessationfacilityattheNationalCentreofCardiologyandTherapy,whichhasverylimitedtreatmentcapacity.

Thislackofcapacitytosupportsmokingcessationwithinprimarycareisallthemoreurgentbecause of the high rates of smoking and relatively low levels of awareness about thedangers of tobacco smoke amongst the public in Romania, Bulgaria, the Republic ofMacedonia and the Kyrgyz Republic. All four countries have recently introduced smokingbans for certain enclosed public places. This has created an immediate opportunity forsmokingcessationinterventions.

TheRepublicofMacedoniahasapopulationof2.06millionandsmoking ratesof46% formenand26%forwomen.20Astudyin2008showedthat11.8%ofadolescents(13-15yearsold) were current smokers and 26% had smoked cigarettes. Two thirds of children areexposedtoenvironmentaltobaccosmokingathomeand66%inpublicplaces.21Tobaccoisthe largest agricultural export and there are large government subsidies to encourageproduction. There is no national strategy for smoking cessation. Smoking is “sociallyaccepted“, unlike alcohol or psychoactive substances and is a unique example of the


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implementationofacontradictorydualpolicy,witharestrictivesmokingbaninaccordancewith EU regulations in place along with high agricultural subsidies aimed at stimulatingtobaccoproduction.

Bulgariahasapopulationof7.36millionwith smoking ratesof41% formenand32% forwomen.Publicawarenessofthehealthrisksoftobaccoislow.Ithasoneofthehighestratesof tobacco consumption in the world at 2,822 cigarettes per inhabitant per year.22Anestimated23%ofdeathsamongstmaleswerecausedbytobaccoon2010.Ratesofsmokingamongstchildrenareveryhighwith24%ofboysand31%ofgirlsusingtobaccodaily.23

Romaniahasapopulationof19.5million.Smokingratesare37%menand16.7%women.AccordingtoWHOfigures,77%ofalldeathsinRomaniain2008werecausedbydiseasesforwhich tobacco smoking is themain risk factor.2417%ofRomanianadults aged15oroverwho smoke daily started their daily smoking habit at less than 15 years of age. Ruralresidents (25%)were twiceas likelyasurban residents (13%) tobegin theirdaily smokingbeforetheageof15.25Accordingtosome2015countryreportssmokingtobaccoisexpectedtogrowovertheforecastperiod,mainlyduetothefactthat“rollyourown”tobaccoisseenby Romanian consumers as a convenient and legal cheaper alternative to cigarettes. Thegrowing range of brands available and strengthening brand visibility in stores may alsostimulatedemandfortheseproducts.26 Romania istheEUcountrywherepeoplearemostexposedtotobaccosmokeatwork.27

TheKyrgyzRepublichasapopulationof6millionwithsmokingratesof36%formen,3%forwomen and the highest standardised mortality rate due to respiratory diseases in theEuropeanRegion.Anestimated17%ofdeathsamongstmaleswerecausedbytobaccoon2010.Thereisalackofawarenessoftheharmfuleffectsoftobaccoamongthepopulationandanabsenceofanyinformationaboutthenecessityoftreatment.Ratesoftuberculosis(TB) are very high. Tobacco use has direct and indirect effects on TB and theWHO hasstrongly recommended co-ordination between national TB and tobacco controlprogrammes.28

StaffandpatientsoutsideaprimarycarefacilityintheKyrgyzRepublicduringarecentIPCRG

visit


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3 TargetAudience

Thetargetaudiencefortheprojectareprimaryhealthcareprofessionalsineachofthefourparticipating countries: Romania, Bulgaria, the Republic of Macedonia and the KyrgyzRepublic. Table 1 below summarises estimated participant and beneficiary numbers. Theprojectwillreachthisaudienceusingacascading‘TeachtheTeachers’model.Thefirstlevelof thismodel involves teachinga small groupof five teachers fromeachcountrywhoareinvolved in continuing medical education, the skills and knowledge required to provideeffectivesupport forsmokingcessation inprimarycare interventions. This initial teachingwilltakeplaceataninternationalteachers’workshop,designedanddeliveredbyanExpertFaculty convened by the project. Teachers to participate in the international teachers’workshopwillberecruitedbyourprojectpartnerineachofthefourcountries.Thiswillbedonethroughopenannouncementoftheprojectandtheopportunitytoparticipateineachpartners’network.ExcellentEnglishlanguageskillswillbearequirementastheinternationalteachers’workshopwillbeconductedinEnglish.

Thesecondlevelofthe“TeachtheTeachers”model involvestheseteachersthenteachingother primary healthcare educators in their own countries the skills and knowledge theyacquiredattheinternationalworkshop.Thiswillbedoneatin-countryworkshopsthatwillbeorganisedusingtheestablishedCMEsystemsineachcountry.Indoingso,theywilluseresources which have been adapted for their own context and take place in the locallanguage.TheprimaryhealthcareeducatorsparticipatingatthislevelwillberecruitedfromtheexistingnetworksofourprojectpartnerswhoareprovidingCME.

Thethirdlevelofthe“TeachtheTeachers”modelistheprimaryhealthcareeducatorsthenproviding modules to improve the knowledge, skills and confidence for treating tobaccodependence in their community for GPs, FPs,medical assistants, nurses and pharmacists.Theprimaryhealthcareprofessionalsthatparticipatewillusethenewskillsandknowledgein their daily interactions to provide tobacco dependence treatment to patients who aresmokers.Thesepatientsarethebeneficiariesoftheproject.Itisnotpossibletodetermineexactnumbersofpatientbeneficiariesasthisdependsonthesizeofthepatientlistoftheprimaryhealthcareprofessionalswhoparticipate,thepercentageofthesewhoarecurrentsmokersandthe frequencywithwhichtheyvisit theirprimaryhealthcareprovider.Astheprevioussectionofthisproposalhasexplained,smokingratesineachofthefourcountriesare high and evidence shows the vast majority of smokers see their primary healthcareprovideratleastonceayear.Table1belowincludesaveragepatientlistsizeandusesthistoestimate the potential number of current smokers who are likely to benefit fromconsultations with primary care professionals who have participated in the project. Theestimateusesthe followingconservativeassumptions:patientssmokeat thesamerateascurrent smoking rates ineachcountry;patientsaremadeupequallyofmenandwomen;20%ofpatientsarechildrenunder18whoarenon-smoking;50%ofthesesmokerswillseetheir FP/GP once a year. Even using these conservative estimations it is clear that manythousandsofpatientswhoarecurrentsmokerswillbenefitfromconsultationswithGPsandFPs who have increased capacity to treat tobacco dependence as a result of theirparticipationintheproject.

BecausetheprojectbuildsanetworkofteachersembeddedinexistingCMEnetworks,theteachingontobaccodependencetreatmentwillbesustainedafterthisprojectiscompleted.Inaddition,ourprojectpartnerswillnegotiatetheaccreditationofthemodulesdeveloped


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by the project for CME and their incorporation into postgraduate education through therelevantacademic,policyandprofessionalbodiesineachcountry.

Table1:estimatedparticipantandbeneficiarynumbers

Activity Macedonia Bulgaria Romania KyrgyzRepublic

Total

Participants in theinternationalteachers’ workshop(1stlevel)

5 5 5 5 20

Participants in thein-country teachingother teachers (2ndlevel)

15-20 15-20 15-20 15-20 60-80

Primary healthcareprofessionals taught(3rdlevel)

250 250 250 250 1,000

Average patientnumbersperGP/FP

1,500 1,300 1,600 800 –1500

Estimateof patientswho smoke perGP/FP

432 379 344 172

Potential totalnumbersofpatientsbenefitingeachyear

54,000 47,375 43,000 21,500 165,875

Our project partners in each of the four countries are experienced in providing CME andhave the necessary networks to recruit the teachers and the participants. The projectpartner in the Republic of Macedonia is the Centre for Family Medicine which has 60educators in all towns in Macedonia who are providing CME in their regions. It hasexperience of developing and implementing a programme for retraining existing generalpractitionersinMacedonia.Thein-countryeducationwillberegionallyorganized,providingenough teachers to cover themedicalprofessionals ineachof the regions in the country.Theseteacherswillthenprovideteachingintheircommunity.ThisteachingwillbeofferedtoallspecialistsinfamilymedicineasaCME.Anestimated250professionalswillparticipate.Familymedicinedoctorsarepaidbycapitationandonaveragetheyhave1500patients.OurprojectpartnerwillnegotiatewiththeHealthInsuranceFundtoputsmokingcessationasanobjectiveofGPsandFPs,sothedoctorscanbeincentivisedtoimplementtheirknowledge.


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BulgarianFPsandGPsatarecenteducationaleventsupportedbyIPCRG

IntheKyrgyzRepublictheprojectpartner istheKyrgyzThoracicSociety,whichhasa largenumberofmembers fromdifferent fieldsofmedicine. Ithasexperience in the trainingoffamily physicians. It will recruit teachers to participate in the international teachers’workshopandthein-countryteachingfromtheNationalCenterofCardiologyandTherapy,Kyrgyz Thoracic Society, the Kyrgyz State Medical Academy, Kyrgyz - Russian SlavicUniversity.MedicalassistantsandcommunitynurseswillbeincludedastheyplayakeyroleinthedeliveryofprimarycareintheKyrgyzRepublic.Theparticipantsallcontributetothetrainingof familydoctors andnursesat theprimaryhealth care level in all regionsof thecountry. In the Kyrgyz Republic every GP, FP ormedical assistant has around 800 - 1500peopleintheirserviceаrеаwhomtheyregularlysee.

InRomania theprojectpartner is theRomanianPrimaryRespiratoryGroup (RespiRo) thatoperates under the auspices of theNational Centre for FamilyMedicine Studies (CNSMF)and the Romanian National Society of Family Medicine (SNMF). Participants in theinternational teachers’ workshop will be selected from among its members. Theinfrastructureofbothorganisationswillbeusedtogoontoteachotherteachersin-country.Primarycareprofessionalstargetedfortheteachingwill includefamilydoctorsandnurses.This existing infrastructure includes two national conferences, eight regional conferencesandover30workshops, symposia, summerschoolandcourseseachyear. Inaddition theon-going Lifestyle project coordinated by the CNSMF (http://cnsmf.ro/proiecte-in-derulare/proiect-lifestyle/) opens access to a network of 100 primary care offices activelyinvolvedinprevention.Theaveragelistofregisteredpatientsis1600perfamilydoctor.

In Bulgaria the project partner is the BulgarianGeneral Practice Society for Research andEducation (BGPSRE). It has experience in developing and delivering many educational


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programmes, for example depression and anxiety in general practice, family planning,tuberculosis and diabetes. It will invite five teachers to participate in the internationalteachers’workshopfromamongitsmemberswhocomefromalloverBulgaria.TheBGPSREiswellplaced todosobecause it isactively involved inpostgraduateandCMEeducation.TheteacherswhohaveparticipatedintheinternationalworkshopwillthengoontoteachothermembersoftheSocietywhoareengagedinprofessionaldevelopment.Allmembersof the BGPSRE are experienced,motivated and engaged in a great variety of educationalprogrammes.TheFPsandGPswhoaremembersoftheorganizationarepractisingactively.TheaveragenumberofpatientsperFP/GPis1300patients,ofwhichabout80%seetheirGPyearly.

4 ProjectDesignandMethods

The project design uses an IPCRG model, ‘Teach the Teacher’, which has been usedsuccessfullyindiverseprimarycarecontextsfordifficulttomanageasthma.29Thisisbasedon a cascadingmodel whereby the international Expert Faculty teaches a small group ofteacherswhothengoontoteachotherteachersintheirowncountries.Theseteachersthenteach primary care professionals new skills and knowledge to confidently treat tobaccodependence. Thisdesigndevelopsasustainablenetworkofteachersandenablesalargernumberofprofessionalstobenefitfromtheteaching.ByusingexistingIPCRGpartnerswhoarealreadyengagedinCMEinthefourcountriesincludedintheproject,wewillmakeuseofexistinginfrastructureandrelationshipstoensurewecanrecruitparticipantsasplanned.

ThecontentandmethodoftheteachingwillbedesignedtoaddressallthefactorsidentifiedascontributingtothepracticegapdescribedinsectionD.2above.Inparticular,thisprojectdesign recognises that CME methods should encompass the complex principles of adultlearning and behaviour change, in addition to teaching new knowledge and skills. Tacitknowledge, relationship building, collaborative learning, confidence building and thoughtleadership are all important in ensuring that education can be used to change clinicalpractice inways that apply knownevidence in practice. Teaching the teachers of primaryhealthcareprofessionalstheprinciplesofadultlearning,aswellskillsandknowledgearoundtreatingtobaccodependence,isthereforeessential.

Theprojectdesignalsoreflectsthatthecontentofteachingontreatingtobaccodependencemustbebasedonwhattheevidenceshowsaboutwhichsmokingcessationinterventionsinprimarycarehavebeenshowntoworkandonmakingthemostofavailableresources.TheNational Centre for Smoking Cessation Training (NCSCT) has explored the evidence foreffective behaviour change techniques for smoking cessation. The behaviour changetechniquescontainedwithintheNCSCTVeryBriefAdvice(VBA)onsmokingtrainingmodulearesupportedbymeta-analyses.30ThisVBAapproachhasthreeelements:establishingandrecordingsmokingstatus(ASK);advisingonhowtostop,includingadvisingthebestwayofstopping smokingwith a combination ofmedication and specialist support (ADVISE); andofferinghelp,whichincludesbuildingconfidence,givinginformationandprovidingsupport,referringtootherserviceswhereavailableandprescribingpharmacotherapy(ACT).

The behaviour change framework that informs this approach is the ‘behaviour changewheel’. This recognises that capability, opportunity, and motivation interact to influencebehaviour, known as the 'COM-B' system. Capability includes having the necessaryknowledgeand skills.Motivation is definedas all thosebrainprocesses that energise anddirect behaviour, not just goals and conscious decision-making. It includes habitual


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processes, emotional responding, as well as analytical decision-making. Opportunity isdefinedasallthefactorsthatlieoutsidetheindividualthatmakethebehaviourpossibleorprompt it.31The COM-B forms the hub of a 'behaviour change wheel' around which arepositioned the nine intervention functions aimed at addressing deficits in oneormore ofthese conditions. These illustrate how our project can have an impact on some of thebehaviours,butwillneedtobesupportedbytheothersixpolicycategories, inadditiontoserviceprovision,that influencebehaviour.Thedeliveryofthiseducationprojectanddataaboutimpactitgeneratescanalsobeusedtoinfluencetheseotherpolicycategories.TheCOM-Bmodelcanapplyequallytothedependentsmokerandtheprimarycareclinician.Figure1:Thebehaviourchangewheel(Michieetal,2011)

The IPCRGwill conveneanExpertFaculty toadviseon theprojectmethodology, includingtheeducationalcontentoftheinternationalandin-countryworkshopsandtheadaptationofeducationalandclinicalresources.Attentionwillbegiventoensurethatthereisfidelitytothekeyeducationalcontent,whileallowing foradaptationto localcontextualandculturalfactorswithinineachcountry.Bio-sketchesfortheExpertFacultymembersareprovidedinsectionHofthisproposal.

Disseminationwill includepublicationoftheproject’soutcomesinapeerreviewedjournaland presentations at national and international conferences on smoking cessation,respiratoryhealthandnon-communicablediseases.

TheprojectdrawsandextendsexistingIPCRGapproachesandinitiatives.In2008itpublishedthefirstConsensusStatementaspracticalsmokingcessationguidanceforprimarycare.SincethentherehasbeenagreatdealofactivitybytheIPCRGandothersintobaccodependencetreatmentimplementationresearch,includinghowtobuildcapacitytotreatinprimarycareindifferentsettings.IPCRGrecentlyproducedanupdateddesktophelperandis


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testingnewinterventionsthroughtwomajorprogrammes,aGlobalBridgesfundedprojectinTrainingcommunityhealthworkersinruralUganda(https://www.globalbridges.org/news/blog/2015/02/10/training-community-health-workers-in-rural-uganda/#.VvzgR4SKDrc)andaHorizon2020fundedFRESHAIRprogrammeofwork(www.theipcrg.org/freshair).IPCRGisalreadyworkingcloselywiththeWHOonprimarycareeducationaboutthepreventionandtreatmentofchroniclungdiseaseaspartofitsnon-communicablediseaseprogrammeanditisimportantweofferpracticalguidancetosupporttheWHO'sstatedambitionfortheprimarycarediagnosisandtreatmentoftobaccodependence(http://www.who.int/tobacco/publications/building_capacity/training_package/treatingtobaccodependence/en/).

The IPCRG drawson thebest global knowledge and practice to developevidence basedapproaches to educational programmes that are adapted for local use by local teams.32Ithasinvestedinbuildingtheeducationalcapacityofitsnetworkandmembercountriesandhas a proven track record in supporting educational implementation.33It recognises thatprimary care cliniciansmust be involved as teachersbecause they recognise local barriersand can identify ways to overcome them. Innovations include the ‘Teach the Teacher’programmethatthisprojectwilluse.

Although the project builds on existing IPCRG initiatives, it does not duplicate current orpreviousactivities. Wehavenotpreviouslyusedthe‘TeachtheTeacher’methodologyfortreatingtobaccodependenceandoursmokingcessationresourceshavenotbeenadaptedforthesefourcountries.Theprojectwillleadtothedevelopmentofarangeofresourcestosupport primary healthcare professionals treating tobacco dependence, includingDesktopHelpers and educational materials translated into local languages and adapted forcontextualdifferences.Thesewillbemadepublicallyavailableatnocost.

5 EvaluationDesign

Wewill conductacomprehensiveevaluationtoensurewecaptureandshare the learninggenerated through our activities and to evidence impact. This is particularly importantbecauseall fourparticipatingcountriesarecategorisedasmiddle incomecountries (MICs)andtheevidencebasearoundeffectivenessandcosteffectivenessofstoppingtobaccouseinterventions in MICs is less developed than that for high income countries, although ingeneralsmokingratesaremuchhigher.Becausethereisnostandardisedwayofevaluatingtobaccocessation trainingprogrammes forhealthcare staff invariedhealthcarecontexts,ourprojectwilluseaframeworkwhichconsidersfivecriticallevelsofevaluation.34

1.Participantreaction-initialsatisfactionwiththetrainingexperience• Usually a post training questionnaire conducted with level 1 (international

teachers), level 2 (in-country teachers) and at level 3 (primary healthcareprofessional).

2.Participantlearning–wasthereanincreaseinskillsandknowledge?• Pre- and post-training assessment of the knowledge of tobacco dependence

treatmentandlocallyavailableresourcestosupportthis,levels1-3.

3. Organisational change & support – variables which helped or hindered training andchangesinprofessionalpractice


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• Feedback on local contextual factors which influenced training andimplementation.On-linesurveyorqualitativeaccountsfromlevel2teachersandlevel3healthcareprofessionals.

4. Participant use of knowledge and skills - transfer of knowledge, skills, development ofprofessionalpractice

• On-linesurveyingofthelevel3healthcareprofessionalswhohavebeentaughtbythelevel2teachersthreeandsixmonthsaftertheirparticipationtoexplorehowtheirclinicalpracticehaschangedasaresult.

5.Patientimpactandoutcomes-overallimpact• Wewill havebaselinedataonnumbersofpatientsperdoctorandnumbersof

smokers.• We will attempt to define indicators and gather data on: provision of VBA,

behaviouralsupport,prescribingpracticeandquitattemptsatpracticelevel.

TheIPCRGhasatrackrecordofdesigningandconductingevaluationsofpartnershipprojectsfunded throughmultiple sources, includingcollectingqualitativeandquantitative researchdata in diverse contexts and publishing evaluation findings in peer reviewed academicjournals.TheExpertFaculty,whichismadeupofseniormedicaleducationalists,behaviourchangeexpertsandclinicians,willdesigntheevaluation.Theevaluationwillbeconductedbyourprojectteam,withJulietMcDonnell,anexperiencededucationalist,asleadevaluator.

Wewilldisseminatethelearning,resourcesandoutcomesfromtheprojectwidelyincludingthrough:

• UpdatesontheGlobalBridgesnetworkthroughoutthedurationoftheproject.• An end-of-project webinar to share the learning from the project on the Global

Bridgesnetwork.• UpdatesontheIPCRGknowledgeplatformwhichcurrentlyhasalmost1,500users.• IntegrationoflearningintoIPCRGsuccessfultoolssuchasDesktopHelpers.• Anarticleonthelearningfromtheprojectsubmittedtoapeerreviewedjournal,and

countryspecificreportsinnationaljournalsofthefourcountries.• Presentationsatnationalprofessionalandspecialistconferencesineachofthefour

countries.• Socialmedia.• Presentationsatinternationalconferences(includingtheIPCRGscientificconference

in May 2017 and the European Respiratory Society international congresses) andlocalnationalconferencesinthefourcountries.

6 DetailedWorkplanandDeliverablesSchedule

The proposed project has seven workstreams. Each of these workstreams, the activitiesinvolved,thetimescaleforcompletionandthedeliverablesaredescribedbelow.

Workstream1:ConveningandsupportinganExpertFaculty

Activities:IPCRGwillconveneanExpertFacultymadeupof:


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• Dr Andy McEwen, an expert in evidence-based behaviour change techniques andExecutiveDirectoroftheNationalCentreforSmokingCessation&Training35;

• DrNoelBaxter,aGPandClinicalLeadforStopSmoking;• DrJaimeCorreiadeSousa,asenioracademicteacherforfamilymedicine;• DarushAttar-Zadeh,anexperiencedcommunitypharmacistandtrainerforsmoking

cessationservices;

This Expert Faculty will design the educational materials, develop and deliver a two-dayworkshop for the teachers and provide support throughout. It will also support thedevelopmentamechanismtoensurethefidelityofthecoreeducationalcontentofthein-countryworkshops.RegularwebinarswillbeheldwiththeCountryLeadsineachofthefourcountriestosupporttheplanningandimplementationofthein-countryteachingofteachersandteachingprimaryhealthcareprofessionals.OnememberoftheExpertFacultywillalsovisiteachcountyoncetoparticipateinin-countryteachingofteachers’events.

Timing:TheExpertFacultywillbeconvenedinmonth2oftheprojectandwillcontinuetoworkthroughouttheproject.

Deliverables: Design of educational materials, delivery of the international teachers’workshop,supportforthein-countryteaching.

Workstream2:Theinternationalteachers’workshop

Activities:IPCRGwillorganiseatwo-dayworkshopfor20teachers,fivefromeachofthefourparticipatingcountries,whichwilltakeplaceinmonth4oftheproject.Thecountrypartnerorganisationswillberesponsibleforrecruitingandselectingtheparticipants.TheworkshopwillbeledbytheExpertfaculty,whowillcontinuetobeavailabletosupportthein-countryphasesofthework.

Timing:Month4

Deliverables:Designofeducationalmaterialsfortheworkshop,deliveryoftheinternationalteachers’workshop

Worskstream3:AdaptationofeducationalandclinicalresourcesActivities: Existing educational and clinical resources will be adapted for each country.36Using existing resources will ensure that approaches taught by the project are evidencebasedandthatthecontentoftheteachingremainsconsistent.

Timing:Months4to8

Deliverables:Educationalandclinicalresourcesavailablefreeonline.

Workstream4:In-countryteachingofteachers

Activities:Countrybasedpartnerorganisationswillworkwithteacherswhohaveattendedtheinternationalteachers’workshoptodevelopanddelivertheteachingtoaround15to20primaryhealthcareeducatorsintheirowncountries.Theparticipantsandspecificactivitieswillvary,dependingonprimarycareinfrastructure.Whereverpossibleusewillbemadeofexistingeventsandcommunications.

Timing:Month6tomonth18

Deliverables:Countrybasedplansforincountryteachingofteachers;in-countryworkshops;inputintoCMEeventsandspecialistconferences


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Workstream5:TeachingprimaryhealthcareprofessionalsActivities:Eachpartnerorganisationwillworkwith the teachers in theircountry todesignand run a programme that builds the capacity of primary care professionals for tobaccodependence treatment. The participants and specific activities will vary, depending onprimarycareinfrastructure.TheExpertFacultywillprovideon-goingsupport.

Timing:Month10tomonth20

Deliverables: Country based plans for in country teaching of primary healthcareprofessionals;in-countryworkshops;inputintoCMEeventsandspecialistconferences

Workstream6:Evaluation

Activities:Designofparticipantevaluationquestionnaires,on-linefollow-upsurvey,analysisandpreparationoffindings,submissiontoapeerreviewjournal.

Timing:On-goingthroughouttheproject;publicationbymonth28

Deliverables:Publicationoftheprojectevaluationinapeerreviewjournal.

Workstream7:Projectcoordination

Activities: Project management, liaising with country partners, financial management,progress reporting to the IPCRG Education Committee and Global Bridges Project Boardwhichwillensurequality;progressreportingtoGlobalBridges.RegularteleconferenceswillbeconvenedwiththeCountryLeadsineachofthefourcountriestoco-ordinateprogress.

Timing:Month1onwards

Deliverables:Regularprogressreportsincludingamid-termreportatM12andafinalreportatM24

The table below summarises the deliverables from the project and the schedule for theircompletion.Deliverable CompletionbyMonthlyteleconferencesofIPCRGandcountryleads On-goingExpertFacultyconvenes M2Programmeandcontentforinternationalteachers’workshop M32-dayinternationalworkshopfor20teachers M4Countrybasedplansforin-countryteachingofteachersproduced M6Adaptedresourcestoeachcountry’sneedsavailable M8Country based plans for in-country teaching of primary health-careprofessionalsproduced

M10

OneExpertFacultymembervisitseachcountry M12MidtermprojectreportforGlobalBridges M12Completionofin-countryteachingofteachers M18Completion of in-country teaching of primary health-careprofessionals

M20

FinalprojectreportforGlobalBridges M24Evaluationpublicationinpeerreviewedjournal M28


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E. References

1McDonnellJ,etal.2014.Buildingcapacitytoimproverespiratorycare:theeducationstrategyoftheInternationalPrimaryCareRespiratoryGroup2014–2020.Viewableat:2WorldHealthOrganization.2008.MPOWER:Apolicypackagetoreversethetobaccoepidemic.WHOLibraryCataloguing-in-PublicationData.Geneva,Switzerland:WHOPress3Papadakis S, PipeA,Kelly S, PritchardG,WellsGA. Strategies to improve thedeliveryoftobaccousetreatmentinprimarycarepractice(Protocol).CochraneDatabaseofSystematicReviews2015,Issue3.Art.No.:CD011556.DOI:10.1002/14651858.CD0115564BaillieAJ,MattickRP,HallW.Quittingsmoking:estimationbymeta-analysisoftherateofunaidedsmokingcessation.AustJPublicHealth.1995;19:129-31.5Royal College of General Practitioners. The 2022 GP. Compendium of Evidence. RoyalCollege of General Practitioners, London. 2013http://www.rcgp.org.uk/~/media/Files/Policy/A-Z-policy/The-2022-GP-Compendium-of-Evidence.ashxAccessed10February2016.6Jorm LR, Shepherd LC, Rogers KD, Blyth FM. Smoking and use of primary care services:findingsfromapopulation-basedcohortstudylinkedwithadministrativeclaimsdata.BMCHealth Serv Res [Internet]. BioMed Central; 2012 Aug 18;12:263.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3502263/Accessd10February20167 Fiore MC et al. Treating tobacco use and dependence: a clinical practice guideline.Rockville,MD,U.S.DepartmentofHealthandHumanServices8TobaccoAdvisoryGroupoftheRoyalCollegeofPhysicians.NicotineaddictioninBritain;areport of the Tobacco Advisory Group of the Royal College of Physicians. London, RoyalCollegeofPhysiciansofLondon,20009PapadakisS,etal.2015.Strategiestoimprovethedeliveryoftobaccousetreatmentinprimarycarepractice.CochraneDatabaseofSystematicReviews2015,Issue3.10Panaitescu C, et al. 2014. Barriers to the provision of smoking cessation assistance: aqualitativestudyamongRomanianfamilyphysicians.NpjPrimCareRespirMed11Cadrulegislativ,CNASviewableat:http://www.cnas.ro/page/cadru-legislativ.html12SpasovskiM,LazarevikV.StudyonuseoftobaccoandtobaccoproductsamongmedicaldoctorsintheRepublicofMacedonia.Ministryofhealth,2014.13 Smith DR, Leggat PA. An international review of tobacco smoking in the medicalprofession: 1974--2004. BMC Public Health [Internet]. 2007;7(1):1–12. Available from:http://dx.doi.org/10.1186/1471-2458-7-11514SpasovskiM,LazarevikV.StudyonuseoftobaccoandtobaccoproductsamongmedicaldoctorsintheRepublicofMacedonia.Ministryofhealth,2014.

15Walker N et al. Cytisine versus Nicotine for Smoking Cessation. N Engl JMed [Internet].2014Dec18[cited2014Dec18];371(25):2353–62.16West R, et al. 2011. Placebo-controlled trial of cytisine for smoking cessation. N Engl JMed.2011;365(13):1193-1200.17WHOReportontheGlobalTobaccoEpidemic,2015CountryprofileTheformerYugoslavRepublicofMacedonia18Panaitescu C, et al. 2014. Barriers to the provision of smoking cessation assistance: aqualitativestudyamongRomanianfamilyphysicians.NpjPrimCareRespirMed

[Internethttp://www.nature.com/articles/npjpcrm201422].19Panaitescu C,Oana SC,Manea V,Chiriti M,Anghelescu P,Angelescu D. Smokers whowant to quit prefer their GP advice and support: a six months evaluation study in a


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primary care practice group. Paper presented at International Primary Care RespiratoryGroupWorldConference;Seville;2008May28–3120Smokingratesasin2015editionoftheTobaccoAtlasviewableat:http://www.tobaccoatlas.org21Kosevska E, Polozani A, SpasovskiM and all. Global Youth TobaccoUse Prevalence andExposure to Environmental Tobacco Smoke in the Republic of Macedonia in 2008;MacedonianJournalofMedicalSciences.2010;2(3)245–254.22 Towards a Smoke Free Europe infographic. Available athttp://www.ensp.org/extra/smoke-free-europe/infographic.html23Smokingratesasin2015editionoftheTobaccoAtlasviewableat:http://www.tobaccoatlas.org24WorldHealthOrganization,MinistryofHealthRomania.GlobalAdultTobaccoSurvey,Romania2011.Availableat:http://www.who.int/tobacco/surveillance/survey/gats/romania/en/index.html25WorldHealthOrganization,MinistryofHealthRomania.GlobalAdultTobaccoSurvey,Romania2011.Availableat:http://www.who.int/tobacco/surveillance/survey/gats/romania/en/index.html 26SmokingTobaccoinRomania,EuromonitorInternational,availableat:http://www.euromonitor.com/smoking-tobacco-in-romania/report27 Towards a Smoke Free Europe infographic. Available athttp://www.ensp.org/extra/smoke-free-europe/infographic.html28ForafulldiscussionseeJeyashreeKetal,Smokingcessationinterventionsforpulmonarytuberculosistreatmentoutcomes.2014.29Seethesummaryreportavailableat:http://bit.ly/1EAtbN130Aveyard, P., Begh, R., Parsons, A. and West, R. Brief opportunistic smoking cessationinterventions:asystematicreviewandmeta-analysistocompareadvicetoquitandofferofassistance.Addiction.2012.doi:10.1111/j.1360-0443.2011.03770.x31Michie S, van Stralen MM, West R. The behaviour change wheel: A new method forcharacterising and designing behaviour change interventions. Implementation Science : IS.2011;6:42.doi:10.1186/1748-5908-6-42.32McDonnellJ,etal.2012.EffectingchangeinprimarycaremanagementofrespiratoryconditionsPrimaryCareRespiratoryJournal.2012.21(4).431-436.33 See for example details of the IPCRG’s E-Quality programme which seeks to increaseeducational capability in member and associate member countries:http://www.theipcrg.org/display/EDUEQU/IPCRG+E-Quality+Programme34Guskey,T.R.,1999.Evaluatingprofessionaldevelopment.CorwinPress.(Adapted)35Seehttp://www.ncsct.co.uk36IncludingtheIPCRGDesktopHelper:Helpingpatientsquitsmoking:briefinterventionsforhealthcareprofessionals.Availableat:http://bit.ly/1PbwV0Y

Documents

FINAL PROPOSAL TO GLOBAL BRIDGES A. Project …...Final proposal from the IPCRG (Project ID: 25678413) 3 C. Reviewer Comments None received. D. Main Section of the proposal (not to