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Background: By 2030, 80 % of the annual 8.3 million deaths attributable to tobacco will be in low-income countries (LICs). Yet, services to support people to quit tobacco are not part of routine primary care in LICs. This study explored the challenges to implementing a behavioural support (BS) intervention to promote tobacco cessation within primary care in Nepal.Methods: The study used qualitative and quantitative methods within an action research approach in three primary health care centres (PHCCs) in two districts of Nepal. Before implementation, 21 patient interviews and two focus groups with health workers informed intervention design. Over a 6-month period, two researchers facilitated action research meetings with staff and observed implementation, recording the process and their reflections in diaries. Patients were followed up 3 months after BS to determine tobacco use (verified biochemically) and gain feedback on the intervention. A further five interviews with managers provided reflections on the process. The qualitative analysis used Normalisation Process Theory (NPT) to understand implementation.Results: Only 2 % of out-patient appointments identified the patient as a smoker. Qualitative findings highlight patients' unwillingness to admit their smoking status and limited motivation among health workers to offer the intervention. Patient-centred skills needed for BS were new to staff, who found them challenging particularly with low-literacy patients (skill set workability). Heath workers saw cessation advice and BS as an addition to their existing workload (relational integration). While there was strong policy buy-in, operationalising this through reporting and supervision was limited (contextual integration). Of the 44 patients receiving the intervention, 27 were successfully followed up after 3 months; 37 % of these had quit (verified biochemically).Conclusions: Traditionally, primary health care in LICs has focused on acute care; with increasing recognition of the need for lifestyle change, health workers must develop new skills and relationships with patients. Appropriate and regular recording, reporting, supervision and clear leadership are needed if health workers are to take responsibility for smoking cessation. The consistent implementation of these health system activities is a requirement if cessation services are to be normalised within routine primary care. [ABSTRACT FROM AUTHOR]

Experience shows that planners need to consider the effect of the process of decentralisation on national health programmes. The aim of this article is to explore the relationship between decentralisation and a national disease control programme by seeking to understand the views and attitudes of staff working in a national TB control programme on the process of change and their involvement in that change. The study to which this paper refers was performed in Nepal, where, in common with several low- and middle-income countries, a Local Self Governance Act has been passed and decentralisation is in the process of being introduced in the health sector. The aim of the study was to develop a process of initial dialogue among programme staff with a view to exemplifying those enabling and disabling factors which could influence the process and content of health systems development and its impact on health and health care. The study used individual interviews and group discussions to increase our understanding of the experience of different stakeholders at both national and district levels. Important problems identified include: confused lines of authority, difficulties of integrated supervision, poor career paths and promotion possibilities, unclear performance management, lack of priority to be given to health and TB control, lack of local accountability, lack of capacity and the risk to the drug supply. The study highlights the need to (a) develop consensus techniques, achieve a balanced appreciation and include all stakeholders in the process of change and (b) define central and local responsibilities, limiting political bias, maintaining quality control, organising different lines of authority, maintaining priorities and programme integration.