Background
Tobacco use is one of the greatest causes of preventable deaths and disease in human history. According to the World Bank, four‐fifths of the world's 1.1 billion smokers live in low‐income or middle‐income countries [
1]. As per GATS India data (2010) there are 275 million adult tobacco users (rural-216 million, urban-59 million) in India [
2]. About one million Indians die from smoking alone each year, which is 15% of global death burden attributable to tobacco use [
3]. To reduce the economic and health burden from tobacco use, effective tobacco cessation interventions are clearly needed.
Tobacco cessation interventions by healthcare providers hold promise in improving quit rates. Several studies have demonstrated that asking about smoking and offering advice about cessation increases quit rates [
4,
5]. However, little is known about the extent of adherence with the tobacco cessation interventions in primary care in India. A study by Panda et al. in 2011 among physicians in primary care facilities in India suggests that tobacco cessation interventions were not being offered in primary care clinics to any significant extent and patients were not benefiting from opportunistic counseling advice [
6]. No simple empirically validated model captures the broad range of interventions across tobacco but the 5As construct provides a workable framework to report tobacco cessation interventions. The 5As include ‘
Asking’ all patients about tobacco use, ‘
Advising’ tobacco users to quit, ‘
Assessing’ tobacco users’ readiness to quit, ‘
Assisting’ patients in their quit attempts, and ‘
Arrange’ follow-up visits and counseling. Although the 5As approach is becoming more widely adopted as a strategy for behavior change counseling in tobacco cessation, practical and standardized assessments of 5As delivery are not widely available in the developing world and this is true also for India [
7]. Accurate measures of providers’ delivery of tobacco cessation efforts during clinical practice are needed to monitor providers’ adherence to the 5As approach and to assess the impact of interventions [
8]. Provider treatment of tobacco use can be measured by patient surveys, provider surveys, medical record reviews, and direct observation [
9]. We assessed physicians’ adherence with the 5As intervention by conducting surveys simultaneously with both physicians and patients respectively. We also assessed the concordance on physicians’ and patients’ report of the 5As intervention by measuring extent of agreement between physicians and patients report on the 5As intervention. We further explored patients’ agreement on 5As intervention in relation to their quitting behavior. The study was conducted in selected health facilities providing primary care.
Discussion
The 5As intervention is an evidence-based approach for tobacco cessation and is feasible to apply in primary care. This study describes adherence with the 5As intervention for tobacco cessation and concordance between patient
-provider delivery and receipt of 5As interventions respectively. We captured both patients’ and physicians’ responses simultaneously without a lag period. Globally, patients’ view on quality of behavioral interventions has been captured in previous studies [
12,
13] however, no studies have assessed physician and patient report of the 5As in tobacco cessation in India.
The findings of the current study are consistent with the findings of previous work [
14,
15] in which the majority of physicians self-report that they ‘
Asked’ patients about tobacco use. Our finding related to asking patients about tobacco use is also in agreement with the study by Conroy et.al. [
16] where 76% of the patients reported that they were asked for tobacco use during their visit to physicians. However, on examining physicians and patients responses we found that there is slight agreement between physicians’ and patients’ responses regarding the
‘Ask’ component of 5As intervention. The high percentage reported on
‘Asking’ component by patients is promising as asking for tobacco use is very often the first step towards a more comprehensive cessation intervention.
Our data suggest that most physicians do not ‘
Advise’ patients to quit. Similar findings were observed in GATS, India (2010) data [
2], studies by Thankappan et.al. [
17], and Mas et.al. [
18], which also found that less than 50% of physicians are routinely advising patients to quit tobacco. When we assessed agreement between physicians and patients report, we found low agreement on ‘
Advise’ component of 5As intervention as has also been reported by Pollak et.al, in 2002 [
19]. When patients attend primary health facilities, an enquiry about tobacco exposure by a physician and brief advice to quit can increase the rates of tobacco cessation [
20]. Unfortunately, these opportunities were largely missed by physicians in our study.
A recent meta-analysis highlights the effectiveness of
‘Assess’ intervention and suggests that prior assessment of willingness to quit excludes many tobacco users who would have taken up the offer of assistance if offered directly [
21]. However, clinical practice guidelines recommend assessment of willingness as an important step which further provides a roadmap for tobacco cessation treatment [
10]. Our findings indicate that though a majority of physicians self-reported that they
‘Assess’ patient willingness to quit, only a few patients reported being
‘Assessed’ by physicians. Low agreement on ‘
Assess’ intervention between patients’ and physicians’ report was observed. Although it is possible that patients underestimated physician assessment, the fact that they did not recall a physicians’ assessment strategy is clinically important and suggests the need for more intensive interventions in the primary care setting.
In contrast to physicians’ self-reported practices, patients in our study mentioned that only a few physicians ‘
Assisted’ them with their quit attempts. Similar findings were observed in studies conducted in other settings [
22,
23]. Our findings also indicate low agreement between physicians and patients on the ‘
Assist’ component of 5As. This is a cause for concern as it suggests that physicians are not offering adequate support to help patients quit tobacco despite strong recommendations by national guidelines which give emphasis to assist patients in quitting tobacco [
10].
In our study, the majority of physicians self-reported that they ‘
Arrange’ follow-up visits for the patients. However, patient surveys reveal contrasting findings. We found slight agreement on ‘
Arranging’ for follow-up visits and this finding is similar to a study reported by Omole et.al.in South Africa in 2010 [
23]. The slight agreement on follow-up support is promising and underscores the need for a pragmatic approach incorporating checklists into system reminders to prompt physicians to provide information on follow-up counseling sessions and support [
9].
Similar to the findings of our study, studies conducted in other South
-Asian countries reported discordance between rates of ‘
Advise’, ‘Assess’, ‘Assist’ between physicians and patients [
24,
25]. We reason that this discordance could be because patients often underestimate physicians’ interventions. The concern of patients about their personal medical problem may have affected their responses [
26].
While many studies report on the issues of concordance, there are few which have examined the relationship of agreement to quitting behavior. We explored the association of agreement on 5As intervention with patients’ quit attempts. Our findings are similar to the findings reported by Quinn et al. who suggests that patient who made a quit attempt had higher agreement on receipt of 5As as compared to those patients who did not attempt to quit [
26].
Our findings, although insightful, need to be interpreted cautiously as the patient survey was conducted in a subsample of health facilities providing primary care, and thus may not be representative of the overall health care experience in primary care settings. The patients’ responses were captured at the time of their visit to the health facility. However, the questionnaire captured physicians’ responses and 5As interventions over a period of 12 months. Thus, physicians were more likely to overestimate their practices in the present study. Further, these results are based on reports from patients and do not reflect the notations from the medical record. Ideally, an audit of the physicians’ records would better validate findings from the surveys. However, considering that medical records of physicians are not currently maintained in India as in other developing countries, patient interviews are likely to be the best available evidence on the 5As interventions of the physicians.
Conclusions
In conclusion, concordance between physician and patient self-report is slightly higher for ‘Ask’ and ‘Arrange’ and low for ‘Advise’, ‘Assess’, and ‘Assist’ interventions. Our study suggests an urgent need for revising current strategies in order to strengthen the ‘Advise’, ‘Assess’, and ‘Assist’ interventions in tobacco cessation in primary care settings. This study helped developed what we believe is the first comparison of behavioral health interventions (5As) in India by using two standard surveys capturing both physician as well as patient responses at the same time.
We propose that patient surveys such as ours should be used routinely in assessing fidelity and provider adherence for large scale behavioral health programs especially in the areas of non-communicable disease program. Further research is needed in order to determine the true rate of tobacco cessation intervention in primary care settings, assess barriers towards provision of tobacco cessation services as well as to verify trends in patient and physician reports in India and other developing countries.
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Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
DP, RP, SV conceptualized and planned the overview of the manuscript. RP was involved in designing and conducting the study as well as the design of the manuscript. DP contributed to the interpretation and writing of the results and discussion. SV led the data analysis. JSA reviewed the manuscript and provided critical inputs relating to quality and content of the manuscript. All authors read and approved the final manuscript.