Working with the target group
Role development
The outreach workers initially shared the view that their primary function was to increase awareness in Bangladeshi and Pakistani smokers about local stop smoking services and encourage use among those wishing to quit smoking. They anticipated that their working methods would develop with experience, and through trial and error.
"I think until you go out there and try some of these methods out you wont really know which one will be most effective, which one will be the least effective and I think that's what the whole of this project is really about having a bit of trial and error... And that's what's within the flexibility of outreach is the ability to change and swap and use that to explore different avenues." (Samir, FG1)
The importance of building relationships with individuals was frequently mentioned. Outreach workers agreed that gaining the trust and respect of the community was essential to relationship building.
"It's about building the relationship, building the rapport and as soon as they see that okay this person is here for my benefit then they will start opening up. This is how our culture works." (Samir, FG1)
However this was sometimes a challenge during outreach on the streets, as some people were suspicious of their motives. In an attempt to dispel suspicions, they sometimes adapted their approach depending on the age and language spoken by the individual, for example, using "street language" and "buzz words" with younger smokers and addressing older smokers as "uncle" to gain respect. The NHS was frequently mentioned as it is trusted by most Bangladeshi and Pakistani people.
Outreach workers believed that developing their local profile was essential to forming relationships with the community. This involved using publicity, for example, handing out business cards and by word of mouth. They approached Pakistani and Bangladeshi people opportunistically on the streets around shopping areas. They believed that their repeated presence in the community would, over time, help develop trust. This appeared to work, because some smokers who were initially unwilling to quit subsequently approached the workers for advice on quitting.
"Signed up client whom I had seen several times on Coventry Road and is now ready to try and quit." (Rashed, diary entry)
Outreach workers believed that their acceptance by the community was because they shared the same ethnicity and/or religion. During observations, exchanges with potential clients were often initiated through outreach workers expressing their identity. Initial exchanges often involved shaking hands and using the religious expression "Assalamu alaikum" ("Peace be with you"); thus immediately expressing their religious identity. Additionally, conversing in Bengali, Urdu or Mirpuri identified the outreach worker as of Bangladeshi or Pakistani origin. Outreach workers emphasised that they were there to specifically help Pakistani and Bangladeshis. They believed that such displays of communality offered reassurance, facilitated communication, and generated respect for them and their role.
"It helps to relate, for them to relate to you, doesn't it? Because if they feel you're from the same country or if you're not from the same country it's the same religion, they can relate to... they feel they can relate to you. I think that's why they ask these questions: where are you from, are you Muslim... or whatever." (Tariq, FG4)
Encouraging cessation
Outreach workers believed that concerns about the likely health impact of smoking were a key lever to enhancing smokers' motivation to stop. Messages were tailored to age and interests. For young men, particularly those interested in physical activity, the benefits of having a healthier lifestyle were emphasised. This was reinforced by offers of free use of local city council gyms if they signed up to the stop smoking programme.
"For the younger generation we would highlight the things on terms of, for example, sport, activities, holidays, things that they could get, buy." (Wasim, FG4)
In contrast older men were reported as being unaware of the major health consequences of smoking except lung cancer. They therefore frequently discussed the benefits of quitting for short-term and long-term health.
"Just simple things, like circulation, when you explain to them about how it effects the circulation, they say 'oh yeah, that's why in winter my hands and feet are always cold'. And we explain that, well, if you did stop that would improve within 20 minutes. And, like, they're quite surprised." (Rashed, exit interview)
Smokers were also advised of the financial benefits of stopping smoking, for themselves and their family. The effects of smoking on the family were frequently discussed with smokers and also the wider community (typically non-smoking women) at various community events. Most thought that this was useful, but one outreach worker doubted this. He believed that coercion by family members was not always helpful as it could attract smokers who were not fully committed to quitting and would drop out.
"If it was a man that was supposed to have come for an appointment or he has started a programme, he's not coming here because he really wants to stop, its because he's been coerced by his wife or his mom or he's being pushed into it and he's not ready to stop, that seems to be the main problem. But where they have come for themselves, the drop-out rates are very low." (Tariq, exit interview)
In contrast, another outreach worker argued that targeting families could reduce passive smoking, citing several cases where family members had banned smoking in their home.
Outreach workers often used "shock" tactics through pictorial images and visual props. They developed culturally specific posters and leaflets and used feedback to refine these before distributing them to the public, community networks, and pharmacists.
"The fact that they're smoking the rat poison stuff that they've got in their shops, they can't believe they've got these items in them and that's what's been working for me" (Samir, MM1).
Encouraging use of pharmacological therapies
Bangladeshi and Pakistani smokers were reported to be lacking in knowledge about and belief in pharmacological aids to quitting. Although many smokers knew of and had used nicotine replacement therapy (NRT), they had done so inappropriately. Some thought that using NRT would make them want to stop smoking and that, if it had not done so, it did not work.
"What happened was originally they would have come back to us and said, 'Oh, I've tried to stop smoking before with this patch and it didn't work for me'. But when you explain to them or you ask them as to how they used it, that's when you find out they haven't been doing it properly or they borrowed the patch from somebody else or they've got one from their friends or cousins or family or etc as a one-off." (Wasim, FG5)
Outreach workers attempted to correct these misconceptions, making smokers more aware of the purpose and benefits of using NRT - for example, referring to NRT as a form of medication in order to emphasise the importance of completing a full course of treatment.
"Some of the people didn't see it as a medication until we spoke to them basically. So a lot of people don't think it's an option, they think it's just like a gimmick." (Wasim, exit interview)
During Ramadan, when Muslims fast during daylight hours and cannot eat, drink or smoke, advice about NRT was tailored specifically to the individual's religious beliefs. There were, for example, differences in views about the religious legality of using NRT patches during daylight hours. Where people had reservations they were advised to use patches upon completion of a day's fast.
Difficulties in encouraging cessation and use of stop smoking services
The most common challenge cited was Bangladeshi and Pakistani smokers' lack of interest in stopping smoking. Young people were particularly unwilling to quit, even though they knew more of the health risks than older smokers, as they enjoyed smoking.
Both Bangladeshi outreach workers stated that, compared with Pakistani smokers, Bangladeshi smokers were harder to motivate to access the services and were less likely to want to quit. However, if they made the commitment to change, Bangladeshi clients were perceived to be more committed to the stop smoking programme than Pakistani clients.
"The thing is with the Pakistani community, if they're easier to convince to try it, they might give it a go or they might not be fully into it, rather when... you know like I said its difficult to motivate the Bangladeshi community but eventually when they do come through it seems to be like, they're really like committed." (Rashed, exit interview)
Addressing smokers' negative attitudes towards seeking and receiving help from the stop smoking services was also a challenge. Some questioned the value of the support and advice offered by the cessation service, particularly if they had never experienced support previously. Others believed that they could quit without assistance.
"...another thing is they have this attitude that the support, I mean 'What's that going to do for me?'" (Rashed, exit interview)
Outreach workers also found that smokers who lapsed during their quit attempt were reluctant to come back for their weekly session, believing this disqualified them or because they felt ashamed.