Reaching Routine and Manual workers that want to stop smoking
The aim of NHS Kirklees’ reaching routine and manual workers that want to stop smoking project was to increase the number of routine and manual (R&M) workers accessing the NHS Kirklees Stop Smoking Service.
R&M workers who smoke have been identified as a major health challenge at a national level (Department of Health, 2010). NHS Kirklees Public Health tobacco control programme set out to achieve its aim through building upon initial insight with stakeholders to develop a targeted stop smoking service that incorporated other health issues (such as weight and stress management) as well as making it feel like more like a ‘club’. These insights also helped form targeted promotional materials for both males and females and to identify areas where outreach activity would be most effective.
- 30 per cent increase in the number of R&M workers accessing the service and setting a quit date between (2008/09) and (2010/11)
- Increase in the number of R&M workers accessing the service as a percentage of the whole service from 19.5 per cent (2008/9) to 43.8 per cent (2010/2011)
- Increase in 4 – week successful quit rate among R&M workers from 73 per cent (2008/09) to 75 per cent (2009/10). The 4 week quit rate maintained above 60% (2010/11).
R&M workers are identified in the UK as the group with the highest smoking prevalence, making up approximately 44% of all smokers. The disparity between smoking prevalence in routine and manual workers and managerial and professional workers has been identified as a major health challenge at a national level (A Smokefree Future, Department of Health, 2010).
The UK Department of Health have subsequently identified this group as a priority to be targeted and attend services to quit smoking as it is viewed that this will in turn help to reduce health inequalities. (Department of Health, Service and Monitoring Guidance, 2010/11).
NHS Kirklees Public Health tobacco control programme decided to develop a coordinated set of actions to ensure that local interventions, i.e. the specialist stop smoking service, reflected the needs of the target audience in both appeal and content.
A steering group was formed in 2008 with members from NHS Kirklees Public Health Department (commissioners) and Kirklees Stop Smoking Service within provider services.
A project manager from NHS Kirklees took overall responsibility for the commissioning and management of the project. The social marketing manager within NHS Kirklees provided expertise in the planning and writing of research briefs. The stop smoking service manager provided support for the delivery of the pilots and ensured regular communication between organisations.
From the beginning of the project’s conception, the project manager used the NSMC Total Process Planning Model of scope, develop, implement, evaluate and follow-up to provide a structured process to manage the complexities of a social marketing project.
The steering group’s main aim was to gain insight into what would motivate the target audience to seek help to quit smoking, and once at this stage, what would they want a stop smoking service to look like. This insight would then inform pilot interventions that would run for a full year and the final evaluation would highlight which elements should form part of the mainstream service in future.
From census data (2001) NHS Kirklees knew that 32% of the population in Kirklees come from an R&M background. However they identified the need to target Stop Smoking Services at this group more that others due to the smoking prevalence being high in this group and them being notoriously more difficult to get into stop smoking services than other groups.
In order to achieve the desired outcome, a reduction in the number of R&M workers who smoke, NHS Kirklees concluded that the service would need to overachieve on the percentage of R&M workers accessing the service as a whole.
In light of this, the behavioural goals to reduce the number of R and M workers that smoke in Kirklees included;
- Increasing the number of R and M workers accessing and setting a quit date with the specialist service as a comparison to the previous year
- Increasing quit rate with this group
- Increasing the number of R and M workers accessing the service as a % of the whole service
A stakeholder mapping exercise was completed at the start of the project to identify and engage with influential and interested individuals and organisations. It was also used to develop insight into the organisational motivations and barriers to being involved in the project. For example, Kirklees Council leisure services were also struggling to engage this group.
Stakeholder meetings were held at key stages throughout the project to take views, comments and suggestions on board in the planning and next steps.
Stakeholders included representatives from:
- provider services
- Kirklees council
- local sport and leisure clubs
- public health staff
- volunteers (ex service users)
- commissioned market research companies
- private counselling company
- communications staff
- senior commissioners
A stakeholder development session was delivered allowing stakeholders to share their own insights and knowledge. A ‘reverse brainstorm’ activity (generating ideas based on the idea that there are no funding constraints) enabled stakeholders to develop ideas for the project, particularly around how to attract more people to the groups.
The project team knew from the qualitative evaluation, where mock stop smoking sessions were held, that once smokers attended the groups, they by far exceeded their expectations. However, the difficulty was getting them there in the first place. The team used insight from stakeholders to inform the advertising and promotion of the groups in areas where there was a high Routine and Manual audience. For example, at local rugby league clubs and in the local newspapers.
Insight indicated that one of the biggest barriers to attending a stop smoking service was not knowing what happens once you attended a session. Subsequently the project team used press releases to focus on what happened at a group rather than why someone should stop smoking or any health benefits. Input from volunteers was crucial to inform the process and overcome some of these concerns.
Smokefree Kirklees poster before the intervention
The project manager undertook desk research to review research from other areas; nationally, regionally and locally in relation to the target audience. This was with a view to add to the insight pool rather than duplicate work and resource. Information sources included the DH, NHS Bradford and the Kirklees Joint Strategic Needs Assessment. Research revealed there was little guidance on what would drive them to services or what service content should include. The project manager felt that Kirklees specific insight was needed due to the diversity of populations from one locality to another.
A qualitative research company commissioned in April 2008 (stage 1) built upon the desk research. Four focus groups were conducted with smokers from wards identified with high smoking prevalence to develop an understanding of male and female smokers in Kirklees, their motivations to smoke, what smoking offered them and what would be their prime motivator in thinking about stopping smoking or even taking some action.
Two Kirklees localities, Batley and Newsome, were chosen for the pilot based on high smoking prevalence (Current Living in Kirklees, ward level smoking prevalence, 2008). Smokers were also chosen from these localities in the research stages to ensure that views were reflective not just of smokers but from smokers in the areas of interest.
Focus groups included male and female smokers between 20-40 years of age who smoked 20 or more cigarettes a day. These smokers were chosen as they are known to be most dependent on nicotine.
Smokers recruited for focus groups needed to agree with the statements;
- “I am interested in stopping smoking,”
- “I am actively trying to stop smoking but finding it difficult,”
- “I would welcome support when trying to stop smoking.”
The reason for using these statements during recruitment was so that contemplators were being recruited to the research. Most smokers know why smoking is bad for their health; our priority was to find out what the barriers were in accessing support services for people who were thinking about stopping.
In line with the National Monitoring Guidance for Stop Smoking services (Department of Health, Service and Monitoring guidance, 2011/12) the definition of routine and manual workers for the purposes of this project include: electrician, fitter, gardener, inspector, plumber, printer, train driver, tool maker, bar staff, caretaker, catering assistant, cleaner, farm worker, HGV driver, labourer, machine operative, messenger, packer, porter, postal worker, receptionist, sales assistant, security guard, sewing machinist, van driver, waiter/waitress.
The Social Cognitive Theory (Bandura 1999) underpinned the project. It considers how people use/learn certain behaviours and proposes that the development of behaviour is achieved through the interaction of three different factors: personal, environmental and behavioural. The theory stresses the importance of self-efficacy and belief that the benefits of undertaking a behaviour change outweigh the costs.
The Health Belief Model (Becker et al 1978), suggests that an individual is only prepared to change their behaviour if they consider their health to be at risk and believe that they have the confidence to change that behaviour. The project team sought to understand what the target audience knew about the dangers to their health and how confident they were in their ability to make changes to this behaviour.
The Stages of Change model (Prochaska and DiClemente, 1983) helped the project team to focus on contemplators to be able to tailor findings and recommendations to smokers in the target group who might be thinking about change. By doing this they were hoping to reach those who may be receptive to messages and take action rather than pre-contemplators who would block messages and resist action.
Key findings from the qualitative research commissioned in (stage 1) indicated that:
- Female respondents favoured an informal group support service supported by a 24 hour support helpline and online support
- Male respondents wanted one to one support
- both groups would need to be supported by familial encouragement
A key finding from the research that was particularly interesting was that the approach to the sessions favoured by genders was the opposite of how they viewed their own smoking activity i.e. female respondents viewed their smoking as an individual activity and wanted group support whilst men viewed smoking as a group activity and wanted individual support.
Other insight gathered from the focus group research included;
- Chatty, friendly advisor who they can relate to
- Chance to meet others
- Get some ‘me time’
- Don’t want to put on weight
- How will they cope with stress without smoking?
Smokefree Kirklees poster (post-intervention) targeting women
- That it doesn’t feel like AA!
- There is humour
- Information giving
- Focus on outputs e.g. CO monitor and medication
- Opportunity to get fit
- What will they do with their anger and frustration?
One finding common to both research groups is the expectation that the advisor would be an ex-smoker who could relate to their own experiences. This was not something the project team could guarantee, therefore an ex-smoker, who had been through the service and quit, was recruited to support each pilot group. Their role was to act as a “meet and greeter”; showing people to the room, helping them to get a drink and feel relaxed on arrival.
Smokefree Kirklees poster (post-intervention) targeting men
Interestingly through the scoping stage this project understood that the target group (R&M workers) were often the focus for other public health campaigns and particularly smokers were the target of many other health-related messages. This campaign used this knowledge to develop a promotional plan with stakeholders that went outside the ‘usual’ places for health messages (GP Practices, Pharmacies, libraries...) and sort to include them in areas such as supermarkets, shops, public houses, tanning salons and other places where the target audience would go so that it would ‘shock’ them and carry a more potent message.
Following the insight gathered in stage one, the project team commissioned a second formative research agency to find out what male and female routine and manual smokers would want a stop smoking service to look like. This involved testing the settings, formats of stop smoking clinics, communication methods currently employed by the service and understand motivations and barriers to using a stop smoking service.
Key findings from stage 2A included:
- the main differences between genders were in relation to how the stop smoking sessions should be promoted with men preferring slightly more hard hitting lines
- all participants agreed that the biggest barrier to attending a service was not knowing what would happen during a session (fear of the unknown) and that the promotional material should address this
- the session should ideally be run by an ex-smoker, should be informal and non-clinical
- men were interested in the cause and effect information and would welcome advice on health and fitness
- women were excited about incorporating dietary /weight loss advice into the sessions as this was felt to be a real barrier in stopping smoking
- promotion that focused on family had the greatest impact
- promotion that focused on the health impact of smoking was not welcomed
- promotion should use positive reinforcement
Stage 2B involved testing elements of the redeveloped content (including a physical activity element) and promotion of the NHS Kirklees Stop Smoking service in ‘real life’ group settings.
Key findings from stage 2B included:
- women liked the idea of attending a ‘club’
- they liked the added element of the physical activity speaker and felt this helped the group to bond
- they felt that promotional creatives should highlight what the service looks like to overcome this barrier of engaging ‘with the unknown’
The consultation process, including the ‘mock’ group research and stakeholder events were combined with national information to give key concepts that drove the pilot design. This included developing ‘new’ pilot groups based on the key factors that came out of the insight. It meant that the generic service promotion was deemed no longer appropriate and that new materials were needed to focus on the motivators based on insight. More importantly, the project team identified that the motivators and barriers for males and females in this group is quite different and subsequently would require the creation of gender specific promotional materials and strategies.
The insight indicated that female R&M workers see smoking as their ‘me time’ so the service aimed to attract them by selling the service as ‘more of a package’ – escapism and relaxation from the normal routine of life. Sessions are also being held as local as possible to the localities we are targeting are accessible and convenient in order to overcome any such barriers to uptake. Supporting this, sessions were moved to being held after work and a free texting and telephone booking service was introduced and promoted through campaign materials.
“Throughout the evaluation of every ‘block’ of sessions we are continuously striving to find out what the benefits versus costs are of those who have attended the pilots so that we can then use this insight and tailor the pilots as necessary.” Rebecca Elliott - Improvement Practitioner Specialist Tobacco
Recent stakeholder groups have suggested other incentives should be given on completion of the quitting smoking process to add to the recognition/award element.
The service was advertised in areas where the audience would visit or spend time. These locations, such as shops, markets, public houses, etc are places where the target audience enjoy spending time rather than locations where they go for health care or support.
“We did not want the message to be competing with other health messages and insight supported that idea that we should advertise in locations that would surprise them. For example, some of the participants commented that if the promotion was in a GP waiting room, the message would be ignored as it is expected. We therefore targeted areas such as tanning salon waiting areas and working men’s clubs...” Rebecca Elliott - Improvement Practitioner Specialist Tobacco
Both male and female focus groups had a generally perceived feeling that smoking provided; relaxation, relieved stress and an opportunity to socialise. As a result, the project team tried to address these elements in the delivery of the pilots through the introduction of stress management speakers, dieticians and physical activity experts. In order to compete with the social elements, the team also included weeks like bring a friend week to add to the feeling of support.
“We understood that this group has strong competition against stopping smoking in that they enjoy it and that it is part of their culture and tradition, but at the same time this group has strong family values and wants to protect and provide for them. We also know that more often than not, it is this family that causes a large amount of stress which perpetuates the need for smoking even more. We have therefore tried to provide an environment that is tailored to providing some escapism and focus on themselves.” Rebecca Elliot - Improvement Practitioner Specialist Tobacco
An agency were commissioned to build upon the information gathered and to pre-test a number of propositions to understand what this group of smokers would want the content of a stop smoking service to look like, as well as promotional material to attract them to the group. Once the pilot audience and objectives were specified, the pilots were designed with further consultation from routine and manual workers, including delivering a mock group followed by feedback.
A ‘meeter and greeter’ (an ex-service user) was introduced as well as alternative (later) groups from what is currently offered. A text service (based on insight as a preferred method in contacting the service) was also introduced that paid particular attention to detail when contacting the service in terms of a ‘selling crib sheet’.
Service users will be able to self-refer to the pilots by texting or phoning, but some have also turned up on the day. Service users may also be referred from services, including health care professionals, job centres and nursing homes as examples.
As secondary research suggested that by giving people more choice they are more likely to take up the service and regard it of higher value, users were offered more choice in the groups so that people could choose mixed or single sex groups.
Based on the insight obtained through the scoping stage, the service was ‘re-packaged’ to be more like a ‘club’ where participants could informally meet with others going through a similar situation. These changes were subsequently communicated through promotional materials and activities.
The project team introduced later sessions in order to fit them around the target audiences work commitments and increased the number of locations that the service was being run from to those closer to the target audiences’ homes.
Based upon the insight gathered in the scoping stage, promotional materials focused on gender specific advertising to appeal to what was deemed as attractive to males and females in the target audience.
The promotional materials were subsequently distributed in gender specific locations outside of ‘usual’ health promotion settings e.g. female focused posters in nail and tanning salons...
Outreach promotional activities were conducted in locations where a large number of the target audience congregate, e.g. Batley bull dogs and workplace events that target the routine and manual workforce.
The pilot groups started in January 2010 and ran until then end of January 2011. Batley Health centre was the venue for the women’s Time for Me club and Newsome Community High School was the venue for the other group.
The Kirklees Stop Smoking Service was responsible for overseeing the weekly delivery of the groups and advisors with a lead remit for R&M workers were chosen. Kirklees Active Leisure were responsible for delivering the physical activity element of the programme as they were keen to do more outreach work with Women of Childbearing Age (WOCBA) and their partners. The Public Health team at NHS Kirklees had existing expertise within their workforce for the nutrition element and the stress management sessions were commissioned through an external consultancy business. The Public Health project lead pulled all of these elements together.
Implementation of the project was difficult to start with in terms of recruiting smokers to the groups. The team underestimated the amount of resources required for recruitment and the time it would take to dedicate to this agenda. This resulted in the need for the project team to commission an external agency for the face to face recruitment activity, dedicated to driving the target audience, particularly men to the groups.
The outcomes of the groups were monitored by the project lead in terms of quitters. The evaluation agency monitored the qualitative insight relating to the smokers’ experience of the group and this then informed areas for improvement.
When men were presented with the offer of the group that did not require them to go and seek help, it was seen as a far more favourable approach to getting men to attend. Feedback sort from this group suggested that they saw this as an opportunity that they could not say no to as it was made as easy as possible. They also found the reminder text on the day of their group was useful, hinting that if they had not received this reminder, they would have used any excuse not to attend.
The groups themselves were the most successful part of the project, all receiving high quality evaluation with few suggestions for improvement. Even the advisors themselves found the groups useful from a continued professional development perspective.
Evaluation measures were built in from the start of the project. Stakeholders had opportunities to feed into the project at regular milestones throughout the year and evaluation from the smokers themselves was incorporated into the delivery.
The project was evaluated using the following measures:
- Number of referrals to the target localities pre and post intervention
- Number of men and women accessing the service pre and post intervention (setting a quit date)
- Quit rate by locality and occupation
- Number of R and M workers accessing the service as a proportion of the whole service pre and post intervention
Data collected indicated;
- A 30 per cent increase in the number of R&M workers accessing the service and setting a quit date between 08/09 and 10/11
- An Increase in the number of R&M workers accessing the service as a percentage of the whole service from 19.5 per cent (2008/9) to 25.5 per cent (2009/10) to 43.8 per cent (2010/2011)
- Increase in 4 – week successful quit rate among R& M workers from 73 per cent (2008/09) to 75 per cent (2009/10), maintaining a quit rate above 60% for 2010/11
The project was also evaluated qualitatively through an agency being commissioned as part of stage 3 of the project. The evaluation was spread over the 12 month pilot period and allowed for a cyclical approach to amend and/or change the delivery of the pilots.
- Reactions to the service are extremely positive, particularly in comparison to other quit attempts
- Mystery shops to the telephone line suggest that in the main the advisor often imparts key relevant information (without prompting)
- The main strength of the service is the support and encouragement offered in terms of:
- Time spent with individuals
- Discussion amongst the participants
- Encouragement / understanding offered by all staff members (particularly the knowledge that this is available outside the sessions and following on from 7 weeks)
- Non judgemental tone of all staff members
- The format of the groups as women’s only sessions appears to be a motivator to attend and encourages in continuing with the sessions
- The guest speaker weeks are felt to offer relevant and useful content offered by specialists in the field
- The mix of guest speaker and discussion sessions provides a good balance of content
- Practical hints, tips and freebies offered enhances the support given
- Positive reactions to the group – in fact the sessions surpassed expectations
- (Fulfilling masculine stereotypes) the males sought practical hints/tips and goal setting from the group
- The practical teaching aids therefore were successful in getting points across to the group
- Similar to the women’s group the staff and support offered was seen as a key strength
- Potential to extend this support in between weeks and following 7 week block
- In fact some desire for ongoing support – key to ensure participants aware of other services available, this needs to be made more explicit
- The nutrition week was praised as the most positive content due to interactive nature and staff manner
- Similar to findings from the women’s session, the role of the ex smoker was questioned
- Some were put off by one-to-ones at week one taking place in an open room, and queried whether a more private space could be used?
- Potential to make time of sessions slightly later to ensure all R&M workers can attend
Limited recall of promotional material – all males signed up to last service were prompted by face-to-face communications
Areas for improvement
- The role of ex smoker at the sessions was questioned and in some cases their role was felt to be redundant
- Definite role at week one but questioned the ongoing role in support?
- Consideration should be given to the length of the sessions to ensure that participants are gaining the maximum support both from NHS staff and each other
- – Potential for more flexible time slots dependent upon group numbers?
- The next challenge is in attracting more participants to the group
- Some difficulties were experienced in getting through to the phone line and in addition there were inconsistencies in terms of timely follow up calls.
- Overall limited recall of poster amongst women
- Potential for clearer communication of purpose, increased standout and emphasised point of difference over and above drop in sessions eg.
- Tips and techniques
- Chat to ex smoker
- “Expert” and “tailored” advice from guest speakers
- Help to manage stressful times
- Advice to deal with food cravings/practical diet tips
- Support element of the groups
- Highlight bring a friend week as a recruitment tool
- Data capture has been improved (recording of occupational status with less ‘unknowns’ as well as recording of where service users have heard of the service)
- Crib sheets about the groups were created for administrators to ensure consistency of service
- Mystery shops allowed for improvements to be made to the quality of calls
- Mystery shops allowed for improvements to be made to the call back times
The commissioned face to face activity aimed at increasing numbers into the groups found that:
-25% of those spoke to over the 4 days made an appointment
-27% of those who made an appointment actually attended their appointment
“This helped information allowed us to conclude that there may be an issue converting appointments to actual attendance. However we do need to be mindful of the appropriateness of the leads generated and their readiness to change at that time.” Rebecca Elliott - Improvement Practitioner Specialist Tobacco
Following the impressive evaluation results, the project team intend on conducting a further evaluation study on which gender specific promotional materials drew users to the services.
One action that has already been implemented is that the stop smoking service has provided customer service/ telephone skills training for the administrators of the service. The service provider is also keen to continue offering the women only sessions as part of their mainstream service.
Public health staff will review which elements of the project have been most successful and what will become part of the mainstream service. This will be done through the service specification and subsequent performance monitoring of the commissioned service.
Other public health programmes have benefitted from this project as there has been transferable lessons and insights learnt here, such as:
- promotional material to resonate with target audience
- local approach needed, even between localities
- there needs to be a hook (that matters to them) to get your target audience to engage
- Emphasise importance of being non-judgemental in all communications
- Be flexible to respond to pre-testing and interim evaluation findings
The female insight proved favourable toward a female only club and this was something that was not available in the stop smoking service.
Reaching the male audience was challenging because they did not respond to written communication so any posters/leaflets had to have maximum visual impact with minimum text. The project team therefore had to employ other (more proactive) tactics to engage them with minimum effort from them e.g. face to face recruitment.
The amount of work and time commitment needed to raise the awareness of the project was underestimated. If this were to be repeated, more resource (both people and funding) would need to be invested on getting the ‘word out’.
When National Stop smoking services first originated, groups were delivered in a 7 week format. It is only recently that this has changed to a more flexible ‘drop in’ approach. Therefore, the pilot groups were like going ‘back to basics’ for the Stop Smoking staff involved.
The new service has facilitated strong bonding between group members, particularly in the women’s group. This was one of the main insights that guided the development of a more ‘club theme’ to the sessions so is therefore a successful outcome.
Stakeholder engagement was instrumental to the ‘selling’ of the groups to the target audience and raising public awareness through their own appropriate communication channels.
Maintaining communication with stakeholders was therefore key to the project’s success.
The importance of establishing long term ownership and working relationships was found to be fundamental when embarking on a social marketing project, particularly one that may impact on a service provider’s delivery mix in the future. This is perhaps one of the key lessons learnt for future commissioning of tobacco control activities.
The need for baseline data also highlighted a gap in terms of the commissioning of services and being smarter about the priority groups and the level of throughput needed to make a difference to health inequality.