Building capacity for implementation of the framework convention for tobacco control in Vietnam: lessons for developing countries

How do tobacco control policies work in low-income and middle-income countries? A realist synthesis

BACKGROUND

The burden of tobacco use is disproportionately high in low- and middle-income countries (LMICs). There is scarce theorisation on what works with respect to implementation of tobacco control policies in these settings. Given the complex nature of tobacco control policy implementation, diversity in outcomes of widely implemented policies and the defining role of the context, we conducted a realist synthesis to examine tobacco control policy implementation in LMICs.

METHODS

We conducted a systematic realist literature review to test an initial programme theory developed by the research team. We searched EBSCOHost and Web of Science, containing 19 databases. We included studies on implementation of government tobacco control policies in LMICs.

RESULTS

We included 47 studies that described several contextual factors, mechanisms and outcomes related to implementing tobacco control policies to varying depth. Our initial programme theory identified three overarching strategies: awareness, enforcement, and review systems involved in implementation. The refined programme theory identifies the plausible mechanisms through which these strategies could work. We found 30 mechanisms that could lead to varying implementation outcomes including normalisation of smoking in public places, stigmatisation of the smoker, citizen participation in the programme, fear of public opposition, feeling of kinship among violators and the rest of the community, empowerment of authorised officials, friction among different agencies, group identity among staff, shared learning, manipulation, intimidation and feeling left out in the policy-making process.

CONCLUSIONS

The synthesis provides an overview of the interplay of several contextual factors and mechanisms leading to varied implementation outcomes in LMICs. Decision-makers and other actors may benefit from examining the role of one or more of these mechanisms in their particular contexts to improve programme implementation. Further research into specific tobacco control policies and testing particular mechanisms will help deepen our understanding of tobacco control implementation in LMICs.

PROSPERO REGISTRATION NUMBER

CRD42020191541.

Paradox of sustainability in tobacco control in Thailand: A comprehensive assessment of three-decade experiences

BACKGROUND

Over the past 3 decades of tobacco control, Thailand has gained international recognition as a middle-income country with sustained achievement of declining smoking prevalence. However, the number of key Framework Convention on Tobacco Control measures implementation is still far away from the highest-level implementation. As a result, we aim to explore explanatory factors for the paradoxical phenomenon of sustainability in tobacco control in Thailand, to understand what the paradox means, why it happens, and how to take further steps in minimizing the paradox.

METHODS

We used a mixed-method approach comprising qualitative (review of literature and documents plus Program Sustainability Assessment Tool [PSAT] guided key informant interviews) and semi-quantitative methods (PSAT scoring, Theory of Change [TOC], and causal-loop diagram [CLD]) to synthesize all the findings from the qualitative data.

RESULTS

Across all eight domains, sustainability scores at the local level are lower than the national level. The highest total score was in three domains: political support, partnership, and organizational capacity. The lowest total score was for the strategic planning domain. We propose a set of key strategic elements and drivers for future strategic planning.

DISCUSSION

Using CLD, we capture a high-level view of tobacco control with dynamic interactions between contexts, mechanisms, interventions, and outcomes. We believe the deep understanding of tobacco control and the proposed strategy to counteract transnational tobacco companies in Thailand will guide future sustainable actions to reduce the prevalence of smoking, especially in the strategic planning domain that has the lowest PSAT score.

Towards 'a balanced delegation' or enhancing global health governance? Analysis of parties' participation in the Conference of the Parties to WHO Framework Convention on Tobacco Control

INTRODUCTION

The success of the WHO Framework Convention on Tobacco Control (FCTC) depends on parties' active participation in its governance and implementation, particularly via biennial Conference of the Parties (COP) meetings. The COP's efficacy is threatened by declining attendance and reductions in travel support for low-income and middle-income countries, and there are growing concerns about transparency and representation in country delegations amid industry efforts to shape their composition.

METHODS

We examined parties' participation in the COP based on official meeting records, and the relationship between attendance and strength of tobacco control based on national global tobacco control reports.

RESULTS

Attendance at the COP has decreased over time, and at several meetings would have fallen below 66% (the threshold for decision-making) if it was not for high levels of participation among low-income and lower-middle-income countries. Despite their higher attendance at COP meetings, these countries represent a smaller share of meeting attendees due to the smaller size of their delegations. Additionally, there has been a decline in the proportion of delegates from ministries of health and tobacco control focal points. Nationally, COP participation is correlated with stronger tobacco control policies; attendance by low-income countries has a strong correlation with implementation of advertising bans, while attendance among high-income and lower-middle-income countries shows a moderate correlation with implementation of tobacco taxes.

CONCLUSIONS

Supporting states to actively engage in the COP is crucial for ongoing FCTC implementation, strengthening national capacity for tobacco control, and protecting the legitimacy and efficacy of global health governance.

Recommendations on how to achieve tobacco-free nations in Europe

European countries vary widely in the development and implementation of effective tobacco-control programs and policies. Why some countries lag behind others is inherently a political matter. National-level policymakers struggle between the need to protect public health and the need to recognize economic and ideological considerations. Within this context, use of scientific evidence plays an important role in the policy making process. Articles 20 and 22 of the World Health Organisation's Framework Convention of Tobacco Control (FCTC) oblige countries to develop and coordinate research on aspects of tobacco control and require of them to facilitate knowledge transfer and capacity building between countries. This paper considers various ways how EU and national policy makers may accomplish this. We conclude that progress in three areas is needed: 1) generation of more scientific evidence relevant for each country; 2) facilitation of policy learning between countries; and 3) building capacity and collaborations between researchers and tobacco-control advocates to bridge the gap from research to policy, especially in countries with weak tobacco-control infrastructures.

Controlling corporate influence in health policy making? An assessment of the implementation of article 5.3 of the World Health Organization framework convention on tobacco control

BACKGROUND

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) stands to significantly reduce tobacco-related mortality by accelerating the introduction of evidence-based tobacco control measures. However, the extent to which States Parties have implemented the Convention varies considerably. Article 5.3 of the FCTC, is intended to insulate policy-making from the tobacco industry's political influence, and aims to address barriers to strong implementation of the Convention associated with tobacco industry political activity. This paper quantitatively assesses implementation of Article 5.3's Guidelines for Implementation, evaluates the strength of Parties' efforts to implement specific recommendations, and explores how different approaches to implementation expose the policy process to continuing industry influence.

METHODS

We cross-referenced a broad range of documentary data (including FCTC Party reports and World Bank data on the governance of conflicts of interest in public administration) against Article 5.3 implementation guidelines (n = 24) for 155 Parties, and performed an in-depth thematic analysis to examine the strength of implementation for specific recommendations.

RESULTS

Across all Parties, 16% of guideline recommendations reviewed have been implemented. Eighty-three percent of Parties that have taken some action under Article 5.3 have introduced less than a third of the guidelines. Most compliance with the guidelines is achieved through pre-existing policy instruments introduced independently of the FCTC, which rarely cover all relevant policy actors and fall short of the guideline recommendations. Measures introduced in response to the FCTC are typically restricted to health ministries and not explicit about third parties acting on behalf of the industry. Parties systematically overlook recommendations that facilitate industry monitoring.

CONCLUSION

Highly selective and incomplete implementation of specific guideline recommendations facilitates extensive ongoing opportunities for industry policy influence. Stronger commitment to implementation is required to ensure consistently strong compliance with the FCTC internationally.

Technical Assistance to Enhance Prevention Capacity: a Research Synthesis of the Evidence Base

Despite the availability of many evidence-based prevention interventions (EBIs), gaps exist in bringing these programs into widespread practice. Technical assistance (TA) is a strategy for enhancing the readiness of practitioners to implement EBIs. Although many millions of dollars are spent on TA each year, there is little consensus about what the essential features of TA are and how to provide TA with quality. A broad-based research synthesis methodology was used for analyzing the current evidence base for TA using three frames: (1) applying the Getting To Outcomes (GTO) model for categorizing evidence on TA that specifies tasks for planning, implementing, and evaluating TA; (2) understanding the relevance of a successful relationship between the TA provider and TA recipient; and (3) considering the extent to which TA fits the life cycle needs of the preventive intervention. Results indicated that an explicit model or organizing framework is rarely used to plan, implement, and/or evaluate TA; specific TA tasks performed vary widely across studies; TA is rarely delivered to recipients who are seeking to sustain innovations subsequent to adoption and implementation; however, there is systematic attention to relationships and relationship-building. Overall, this synthesis indicates that the extent to which TA is being delivered systematically is limited. We suggest that funders and other stakeholders develop and implement standards for TA quality in order to ensure that many of these limitations are addressed.

Factors influencing tobacco use treatment patterns among Vietnamese health care providers working in community health centers

Background

Almost half of adult men in Viet Nam are current smokers, a smoking prevalence that is the second highest among South East Asian countries (SEAC). Although Viet Nam has a strong public health delivery system, according to the 2010 Global Adult Tobacco Survey, services to treat tobacco dependence are not readily available to smokers. The purpose of this study was to characterize current tobacco use treatment patterns among Vietnamese health care providers and factors influencing adherence to guideline recommended tobacco use screening and cessation interventions.

Methods

A cross sectional survey of 134 health care providers including physicians, nurses, midwives, physician assistants and pharmacists working in 23 community health centers in Viet Nam.

Results

23% of providers reported screening patients for tobacco use, 33% offered advice to quit and less than 10% offered assistance to half or more of their patients in the past three months. Older age, attitudes, self-efficacy and normative beliefs were associated with screening for tobacco use. Normative beliefs were associated with offering advice to quit. However in the logistic regression analysis only normative beliefs remained significant for both screening and offering advice to quit. Over 90% of providers reported having never received training related to tobacco use treatment. Major barriers to treating tobacco use included lack of training, lack of referral resources and staff to support counseling, and lack of patient interest.

Conclusions

Despite ratifying the FCTC, Viet Nam has not made progress in implementing policies and systems to ensure that smokers are receiving evidence-based treatment. This study suggests a need to change organizational norms through changes in national policies, training and local system-level changes that facilitate treatment.