Global Bridges Pre-conference Workshop

1. Global BridgesPre-conference Workshop Dr Lekan Ayo-Yusuf, DDS, MPH, PhD African Region SRNT preconference Meeting, Boston March 13, 2013

2. OBJECTIVE 3 • To facilitate the implementation of Article 14 in every nation

3. 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”.

4. Provision of the WHO FCTC Article 14 • People – HPCs, traditional healers, community workers • Place – clinics, hospitals, schools and community centres • 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

5. A14 guideline: Stepwise approach • 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

6. Use opportunities for tobacco cessation Programmes 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).

7. 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

8. 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 treatmentas part of NCD control in partnership with CSO

9. MEDICATION Evidence-based COUNSELLING (start Brief advice) QUIT LINE Accessible Integrative treatment for tobacco use and dependence Affordable POLICY SUPPORT PUBLIC AWARENESS

10. OBJECTIVE 2 • To provide state-of-the-art, evidence-based training in treatment and advocacy to network members

11. Need to understand effect of policy synergies

12. Prevalence of Current Programs Rigotti NA, Bitton A, et al. An international survey of training programmes for treating tobacco dependence. Addiction 2009 Feb;104(2):288-96. Countries responding to survey (5 Afro countries) Income Level Geographic Region Countries with a current program WesternPacific African European LowIncomeCountries Americas South East Asia EasternMediterranean High IncomeCountries All Countries Middle IncomeCountries

13. 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

14. 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

15. 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”

16. 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.

17. 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)

18. 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

19. Evaluation of training Table 1: Changes in confidence levels to deliver MI following training

20. 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

21. 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

22. Countries represented:~50% of the population GB African Regional network –

23. 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.