Knowledge and practice regarding smoking among staff members of a ...

Community Nursing

Knowledge and practice regarding smoking among staff members of a hospital in Kigali, Rwanda a Nsereko E, MCur b Brysiewicz P, PhD b Mtshali NG, PhD a School of Anaesthesia, b

Kigali Health Institute, Rwanda School of Nursing, University of KwaZulu-Natal, South Africa

Correspondence to: Dr Petra Brysiewicz, e-mail: [email protected]

ABSTRACT Background: The use of tobacco is the single most preventable cause of death and disease in our society and despite the information delivered through materials or messages to increase awareness of the harms of tobacco, many people continue to smoke. Smoking in Rwanda is prohibited in public areas although staff in a large hospital in Kigali continue to smoke. The question arises whether the smoking behaviour of these hospital workers is due to a lack of knowledge regarding the health consequences of tobacco use, and if they are aware of strategies that can be used to help give up smoking. The smoking rates of health workers is important as it has been shown that nurses who smoke are less likely to intervene with smoking cessation programmes with patients and less inclined to advocate tobacco control policies. Method: A descriptive survey was used to establish the knowledge and practices of smoking among staff members of a large hospital in Kigali, Rwanda. A sample of 135 people was drawn from a population of 600 staff members who were working in the hospital for the year 2003. Results: Responses were received from 122 participants. The proportion of smokers amongst the participants was found to be 12.2%, which is higher than the estimation of prevalence of smoking amongst adults in Rwanda (10.6%). Conclusion: Despite a comprehensive ban of smoking advertisements, as well as restrictions on smoking in public areas by the government in Rwanda, the findings in this study revealed that the number of smokers is still high even in settings that offer health care services to the public.

WHO that if the current trends continue, by the year 2030 smoking will kill one in six people.1 Smoking has been described as the single most important cause of preventable death and it has been suggested that it should be classified as the fifth vital sign (along with temperature, pulse, blood pressure and respiration).3

Background The use of tobacco is the single most preventable cause of death and disease in our society1 and despite the information delivered through materials or messages to increase awareness of the harms of tobacco, many people continue to smoke. In 1993, the American Environmental Protection Agency published a significant report on the effects of secondary smoke after an in-depth examination of all scientific literature on this subject. Thereafter, the agency decided to classify the secondary smoking of tobacco as a Group A human carcinogen, reserved for the most dangerous products.2 Exposure to smoking is a prime factor in the development of heart and chronic lung disease, as well as strokes. It can result in cancer of the lungs, larynx, mouth and bladder and it also contributes to cancer of the cervix, pancreas and kidneys. There are approximately 4,000 or more toxic or carcinogenic chemicals found in tobacco smoke.1 Environment Tobacco Smoke (ETS) increases non-smokers’ risk for lung cancer and heart diseases. Amongst children, ETS is also associated with serious respiratory problems, including asthma, pneumonia and bronchitis.2 The World Health Organization (WHO) estimated that approximately one third of the male adult global population smoke and in developing countries smoking is on the increase. Smoking-related diseases kill one in ten adults globally and every eight seconds someone dies from tobacco use. It has been estimated by the ■

The smoking rates among doctors and nurses in 19 Family Medicine Teaching Centres in Bosnia and Herzegovina reflected that approximately 45% of those surveyed currently smoke.4 In a similar study carried out among Greek nurses at a hospital in Athens, the results indicated that 46% of the nurses were current smokers.5 When investigating the smoking prevalence among nursing students in Japan, it was found that 23.5% of the students were smokers.6 The nursing staff in a hospital in Cape Town were surveyed and it was found that the percentage of current smokers was reported as 31.3%.7 The smoking rates of health workers is important as it has been shown that nurses who smoke are less likely to intervene with smoking cessation programmes with patients and less inclined to advocate tobacco control policies.8 It has been suggested that undergraduate nursing training should emphasise the importance of nurses as nonsmoking role models and efforts should be made to involve student nurses who smoke in “quit smoking” programmes in order to reduce the number of smoking students who graduate 27

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as professional nurses.9 It has also been reported that compliance by health workers to a “smoke-free” hospital can be problematic and that without sustained attention to reinforcement and compliance, these policies may be gradually eroded.7

details of the researcher and information about the research project. Participants were made aware that they had a right to withdraw from the research at any point and that participation in the research was voluntary. The return of a completed questionnaire was taken as the participant’s consent to participate in the research. The completed questionnaires were only accessible to the research team.

According to a survey carried out in 2005, 10.6% of Rwanda’s population are cigarette smokers and those under the age of 15 years were reported as the country’s heaviest smokers.10 Rwanda has an annual production of 271,250,000 cigarettes and it is estimated that one person consumes 68 cigarettes.10 Those aged below 15 years consume an estimated 4,016,984 cigarettes. It was reported that 58.9% of secondary school children in Rwanda started smoking between the ages of 11 and 15 years and 54.2% of school going children consume one to five cigarettes daily. Twenty-five per cent consume 11 to 20 cigarettes a day.11 The Minister for Education in Rwanda has spoken out about the shocking habits of smoking amongst school children and has attributed some of the problem to irresponsible parents who do not care if their children smoke at home.10 In Rwanda, the Ministry of Finance has introduced tobacco taxes in an attempt to discourage smoking. The goal of the Rwandan government is to have a tobacco control programme in order to reduce disease, disability and death related to tobacco use by promoting the cessation of smoking amongst young people and adults, and eliminating nonsmokers’ exposure to ETS.12 Laws have also been introduced to prohibit smoking in public places and smoking in Rwanda is prohibited in public areas, although staff in a large hospital in Kigali continue to smoke. The question arises whether the smoking behaviour of these hospital workers is due to a lack of knowledge regarding the tobacco use legislation and the health consequences of tobacco use, and if they are aware of strategies that can be used to help give up smoking.

Data were collected using a 39 item self-administered questionnaire which was developed by Kamanzi14 and permission to use the tool was obtained from the author. This tool consisted of three sections, namely demographics of the respondent, knowledge of smoking and practices of smoking. The data collection instrument was available in English and French. The questionnaire, in collaboration with the salary staff, was distributed along with the payment slips of June 2003. They were placed in the boxes (pigeon holes) of each selected staff member. Staff members were requested to fill in the questionnaire in a maximum of two days and return the completed questionnaire and put it in a secure box located at the main gate of the hospital, where they were collected every day by the researcher. For face and content validity the researcher presented the instrument to the research supervisors to evaluate the content in comparison with the proposed research objectives. For reliability of this instrument a pilot study was conducted to test whether respondents understood the instrument and completed it comprehensively. The researcher carried out test-retest reliability where the instrument was administered to ten members of staff who were not part of the study, and repeated two weeks later to the same members of staff. Scores on the repeated testing were compared and the comparison expressed as a Pearson r. correlation coefficient, which was 0.96, and supports the stability of the instrument.

The Health Belief Model developed by Becker (1984)13 was used as the conceptual framework guiding the study, which was to investigate the knowledge and practice regarding smoking amongst the staff members of a large urban hospital in Kigali, Rwanda. The objectives of this study were to: • Determine the proportion of hospital staff members that smoke • Establish the hospital staffs’ knowledge and practice regarding smoking and its effect on health

Results Descriptive statistics, frequencies and percentages, were calculated using Epi Info 6. A sample of 135 people was drawn from a population of 600 staff members who were working in the hospital in Kigali for the year 2003 and responses were received from 122 participants indicating a response rate of 90%. The proportion of smokers amongst the participants was found to be 12.2% (n=15) and this proportion was higher than the estimate of 10.6% prevalence of smoking amongst adults in Rwanda.11

Method A descriptive survey was used in this study to establish the knowledge and practices of smoking amongst staff members of a large hospital in Kigali, Rwanda. This hospital was chosen as it was the largest hospital in Kigali, and the researcher had access to a large staff population which consisted of doctors, nurses, medical auxiliary staff, technicians, logisticians and administrative staff. The hospital had 600 staff members employed in the year 2003. Simple random sampling was used in this study and the sample size was calculated to be 135 which constitutes the representative sample size in terms of a proportion of 22.5% of the hospital staff.13 All staff members employed had an equal chance to be selected to participate in this study. Names of all staff members were placed in a basket and the first number (first staff) was drawn and systematically other staff members were selected until the sample size was reached.

Demographic data The mean age of the respondents was 31 years, with the majority of the respondents (n=65 or 53.2%), between 18–30 years old, 31.9% (n=39), were 31–40 years old and the remainder, 14.7% (n=18), were 41–60 years old. Of the 122 respondents, 43 were males and 79 were females. Of the 79 female respondents, nine of them are currently smokers and 70 non-smokers. The male staff members had six smokers and 37 non-smokers. When considering the category of smokers (n=15), three of them were doctors, nine nurses, two were secretarial staff members and one ‘other’ staff member. Amongst the non-smokers (n=107), eight of them were doctors, 68 nurses, 25 were secretarial staff members and six ‘other’ staff members. Knowledge of smoking The harmful effects of tobacco on non-smokers who are exposed to it was acknowledged by 82.7% (n=101) of the respondents, with 15.6% (n=19) not agreeing with this and 1.6% (n=2) being unsure. The respondents were asked about their knowledge of diseases caused by tobacco consumption and the results were

Permission to conduct the research was sought from the Director of the hospital after obtaining ethical clearance from the University of KwaZulu-Natal, South Africa. Anonymity of the participants was ensured by not having any identification on the questionnaire. Each questionnaire contained a covering letter giving the contact ■

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to involve student nurses in programmes to quit smoking during their training and to impress upon them the importance of being seen as non-smoking role models by the general public. The dangers of smoking should be incorporated into the pre-registration curriculum of health workers and strategies to help students stop smoking should also be available.5,9 Health workers should be models for healthy living and as such should not be smokers themselves and should attempt to help their patients to stop smoking.

as follows: lung cancer and other forms of cancer 54.9% (n=67) of the respondents, heart diseases 13.9% (n=17), tuberculosis 20.4% (n=25), bronchitis 8.1% (n=10), and brain retardation 2.4% (n=3). All the respondents were asked if they were aware of strategies that may be useful to help quit smoking and 37.7% (n=46) were aware of strategies with 61.4% (n=75) indicating they were unaware of useful strategies to use. Practices of smoking When comparing the ages of tobacco initiation, most (73%) of the current female smokers as well as the majority (46%) of current male smokers started at the age of 17–19 years. Of the smokers, seven had been consuming tobacco for more than six years, six had been smoking for between one and five years and only two of the smokers had been smoking for less than one year. A total of 36.1% (n=44) of the respondents, whether smokers or not, lived with regular smokers whereas 63.5% (n=68) of nonsmokers lived in a smoke free-environment.

Recommendations The hospital has to develop interventions which directly target the smoking staff members. For example, there should be a structured support programme for those who are willing to stop smoking but are failing, and a health education programme which is needs-based should be developed, as some of the programmes are very generic. The hospital may even develop or reinforce its smoking policy as a way of controlling smoking practices within the hospital.

Of the current smokers, the reasons given for smoking were that tobacco is an absolute need (n=6), five said that tobacco gives pleasure, for another one respondent tobacco diminishes anxiety. For two respondents tobacco diminishes anxiety and is an absolute need, and for one respondent tobacco was used to diminish anxiety and to give pleasure.

Conclusion Despite the health impact of tobacco use, strong action to control smoking such as higher taxes, comprehensive bans on advertising and promotion, or restrictions on smoking in public places done by the Rwanda government,12 the number of cigarette smokers is still high, especially in a setting that is offering health care services to the public. The findings in this study also raise a number of interesting issues about the extent to which the staff have knowledge about smoking and its effect on health, and present potential areas to institute smoking cessation interventions.

Of the current smokers, the majority (n=11) expressed the need to give up smoking, whereas four respondents did not want to stop smoking. Of the current smokers, 14 needed help to give up smoking, and only one did not need help in their struggle to stop smoking. More than half of the smokers (n=8) reported to have tried several times to give up smoking. The majority of the smokers (n=10) were willing to give up smoking because they feared the health consequences, and five of the respondents wanted to give up smoking because of the cost of cigarettes.

References: 1. World Health Organisation. Fact Sheet. Smoking statistics. Regional Office for the Western Pacific. [homepage on the internet]. c2002 [updated 2002 May 28; cited 2008 Oct 4]. Available from: http://www.wpro.who.int/media_centre/fact_sheets/fs_20020528.htm. 2. Environmental Protection Agency. Respiratory health effects of passive smoking: lung cancer and other disorders. Office of Research and Development, and Office of Air and Radiation. EPA Document Number 43-F-93-003. c1993 [updated 1993 Jan; cited 2008 Oct 4]. Available from: http://www.epa.gov/smokefree/pubs/etsfs.html. 3. Fiore M C. The new vital sign, assessing and documenting smoking status. JAMA. 1991; 266: 3183-3184. 4. Hodgetts G, Broers T, Godwin M. Smoking behaviour, knowledge and attitudes among Family Medicine physicians and nurses in Bosnia and Herzegovina. BMC Fam Pract. 2004;5(12)5-12. 5. Beletsioti-Stika P, Scriven A. Smoking among Greek nurses and their readiness to quit. Int Nurs Rev. 2006; 53: 150-156. 6. Suzuki K, Ohida T, Yokoyama E, Kaneita Y, Takemura S. Smoking among Japanese nursing students: nationwide survey. J Adv Nurs. 2005;49(3): 268-275. 7. Retief F, Prinsloo E, Calitz J, Barnes JM. Smoking among nursing staff at Tygerberg Hospital, Cape Town. S Afr Med J. 2003;93(9): 661-663. 8. Sarna L, Wewers ME, Brown JK, Lillington L, Brecht M. Barriers to tobacco cessation in clinical practice: Report from a national survey of oncology nurses. Nurs Outlook. 2001;49 (4): 166–172. 9. Nagle A, Schofield M, Redman S. Australian nurses' smoking behaviour, knowledge and attitude towards providing smoking cessation care to their patients. Health Promot Int. 1999;14(2): 133-143. 10. Mukombozi R, Ssuuna I. Smoking in schools irks Minister. The New Times (Kigali). c2006 [cited 2006 Sept 25]. Available from: In allafrica.com. 11. Phukubje M. Rwanda vows to clamp down on smoking. In African News Dimension Johannesburg. 2006. 12. Ministry of Health. Project de loi sur la lutte anti tabac. Rwanda Department of Health. 13. Katzenellegenbogen JM, Joubert G, Karim A. Epidemiology: Manual for South Africa. Cape Town: Oxford University Press; 1999. 14. Kamanzi D. Knowledge and practices of smoking among students of the University of Natal on Durban Campus residences. [Masters thesis]. Durban (SA): University of Natal; 2001. 15. Kamanzi D, Adejumo O. Knowledge and practices of smoking among students in a South African university residence. Africa Journal of Nursing and Midwifery. 2006; 8(1):76-88. 16. Willaing I, Jorgensen T, Iversen L. How does individual smoking behaviours among hospital staff influence their knowledge of the health consequences of smoking? Scand J Public Health. 2003;31(2): 149-155. 17. Laranjeira R, Pillon S, Dunn J. Environmental tobacco smoke exposure among non-smoking waiters: measurement of expired carbon monoxide levels. Sao Paulo Med J. 2000;118 (4):89-92.

Discussion The major dangers associated with smoking were known by the respondents (both smokers and non smokers), although they appeared to have poor knowledge regarding smoking contributing towards heart diseases, bronchitis and brain retardation. This finding was also reported9 where nurses displayed poor knowledge regarding the health risks of smoking, only 50% of nurses were able to name at least five diseases caused by smoking.9 This finding was also reported15 among university students. It has been shown that smokers underestimate the health consequences of smoking as well as passive smoking, and individual smoking habits among hospital workers strongly influence their smokingrelated knowledge.16 From the results, it was noted that 36.1% lived with a regular smoker, and this situation increases the number of the population at the risk of tobacco consequences. A study conducted in Brazil17 regarding environmental tobacco smoke exposure among nonsmoking waiters in a restaurant found that exposure to environmental tobacco smoke was the most likely explanation for the increase in carbon monoxide levels among non-smoking waiters. The results showed that the majority of the respondents were unaware of strategies that may be useful to help them quit smoking. This was reported9 in their study when they concluded that there was a lack of knowledge regarding smoking cessation interventions. It has been suggested that efforts must be made ■

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