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Table 6 Barriers to recruitment and continued engagement – illustrative quotes from pharmacists

From: A mixed methods feasibility study of nicotine-assisted smoking reduction programmes delivered by community pharmacists – The RedPharm study

“the initial consultation takes a bit of time… and because people haven’t been on this programme before, it’s a lot of information to go through whereas the other form [for cessation], a lot of people come in and re-sign up… it’s been running for years so they know all about it, and this is new so, they’ve just a bit more time to get their head around it and explain everything to them and get my head around it as well…What I don’t like about it at the moment is the fact that the whole paperwork and the structure for it is different to the other service…[if] the paperwork was similar, it would be a lot easier… this is all quite new and then… you’re slapping around trying to get the different paperwork and sometimes I think you… just leave it to the patients to come back…if I could… get an appointment from them there and then and get a telephone number…I think that maybe would’ve been a better thing to do. ”PH01
“I think when you try and explain the structured method to them…smoking every so many minutes…I think they look at you a little bit funny… I think they expect to go on the programme and just use the programme to reduce the number of cigarettes themselves and then when you sit and explain all the structure to them it sort of baffled them a little bit” PH01
“I think because of the staffing issues as you’ve seen and the fact of the length of the interviews as well for the first few appointments that’s probably a put off… but with a lot of our patients they’ve not really actively come in and seek to cut down, I think when they come in they’ve made up their minds they want to quit, they want to go all the way… so I think that’s probably the biggest hurdle we’ve had.” PH02
“It was hard to get people on. … they know there is a stop smoking course, and they will come because they want to stop smoking today, but I don’t think a lot of people wake up saying, “I want to cut down…I did ask people, even the people that came in… “Oh, I want to stop smoking” I’d tell them that we were doing the reduction or to stop smoking and they say, “I want to stop smoking, not the reduction.” PH04
“I mean, the cessation programme is short and you have to stop by the second week; whereas this, you get people who go up and down, up and down over the longer period, you know…I think if they had like a barrier, say, ‘By this time you have to have stopped or cut down to this much’, then, I think they will try a bit harder…they knew that they can go up and down and you know it wouldn’t really matter, I think that’s when that probably took advantage of.” PH04
“During the period that it was running we actually managed to recruit about ten people into the stop smoking service, but when I offered… those same people the choice of joining the Redpharm study, they all declined and the reason they declined was because when they were given the choice about being supported or not supported, they didn’t want to take the risk, of being not supported.” PH06
“the reason [that we had difficulty recruiting] I think is it’s a very highly ethnic area and English language isn’t number one medium so with the paper work and the whole bulk that came with it, it was very difficult to explain it to them how the programme worked. So we had initial interest but then nobody carried on… when I explained it further they weren’t really interested because of the technicalities of it…English isn’t their number one language…to explain something that is fairly complex to them it took my time and takes their time …I know trials you have all these technicalities that have to be followed but if it was the programme though we could just go straight into it without the issues surrounding it I think it would work definitely… I did try and recruit, well the initial recruitment as in speaking to them and I also offered them our PCT programme [cessation], which is the standard 12 week programme and they’d rather go for that one.” PH08
“Once you get about eight, nine people on it, it’s… too… time consuming, if it’s..a simple thing just filling the chart, sign it, away you go, it would’ve been easier for me. But… to keep you in behavioural support or, getting people in, saying look how’s it going,…it was time consuming….it just meant that I had to cap the number of people I could take on” PH07
“people didn’t have the understanding that it’s not offered everywhere, a lot of them thought, oh, we’ll go down road and we’ll do it there, or we’ll go closer to home and do it there… and a lot of them… whenever you hear research they think, oh we’re guinea pigs, what’s going happen are you going to give us special drugs, but apart from that, which was a small portion, there wasn’t any problems” PH0
“If you give people the choice between stopping smoking and reduction, they want to stop.” PH10
“The, paperwork is a problem to pharmacists. It’s a bit long and it takes a little long to fill…we’d rather to do it immediately you may try to give someone an appointment to come the next day, in doing so that person may not come so you may end up losing that, and that’s where I find a little bit of a problem. We’d like a shorter level--I know you’re going to collect statistics but, we have to think of a better way to be, to have less paperwork…I think the level of education of most people… possibly was not sufficient for them to understand in detail what this programme was doing to them…There is a big document…in the beginning, and there were, for the patient, the bigger documents that they signed in the beginning, I think some of them don’t like to sign documents, that’s another thing” PH10
“I mean, once they starting losing interest that was it, you know, even the behavioural support people, they would…once they got past the initial appointments, they were just coming in every so and so just to get patches and it’s just one of those things. I think they felt that they weren’t doing anything like on the programme or something…They started off well and after three to four weeks…it just went back up…they would come in and say, “Oh, we’re going to try and do this.” …but then they just go back to normal and then they wouldn’t turn up. So, they start at a level, they go down for a few weeks and then they go back up and then just disappear.“ PH04
“a lot of people left half way because maybe they didn’t see the point, or they didn’t understand the forms that they had to fill, and I can understand but most of them they’d not finished completely so only for four weeks, after that they were tired and they stopped. I have time for them when they come to the pharmacy, but I haven’t got time to start making phone calls” PH10
“when we mentioned to them it’s a year programme… they were a bit reluctant, initially when we say to them, look this is a good programme, you don’t have to quit…straight away, it’s a gradual process so they were impressed it, and then when I gave the information of the little bits, the first, will be about forty five minutes and then it’s for a year you have to really be committed to this programme, then they become reluctant, but the four people I talked to, who’d really benefit from it, they just declined on this, principle… if you were to roll this programme out you probably might need to reduce the number of questions that have been asked, and the… timeframe of the first session, probably needs … at least, fifteen minutes reduction. I think you can get comfortably half an hour somebody come to sit with you, but I think… then, it’s become like a barrier for them, for us to get them to sit twenty minutes in the first session when we do other stop smoking services, it’s already a task….so…”PH12
“after talking to the clients, all gave me that reason is that, this first interview’s too long for us and, we can’t give that much time. And, the other problem is, a lot of the clients here, their English is not, fluent English… we have to speak in their own languages, either in Bengali or, Urdu like that so that’s become, little bit hard.”PH12
“…because we’re offering a smoking cessation scheme as well …I’d give them the option… about which one they wanted to go for, and they all seemed to go for the cessation scheme rather than the reduction scheme, so … didn’t really seem to work over here very well.” PH15
“The cessation scheme is quite straightforward, there’s a bit of paper, the patient comes in, you take a quick… CO reading, you discuss the plan with them, and they just literally come in week in week out to collect their NRT, keep an eye on them… I never really got to have a good, chance with the reduction scheme, but it looked complicated from the outset, that’s my initial view… it’s a randomised trial isn’t it…so obviously, it can’t be as straight forward as a cessation scheme but because of its nature I guess, it just seemed extremely complicated from the outset.” PH15
“they were..like, oh we’re here to stop, but we want a nine month course, and we want your support. And it’s like, well we can’t always, it depends, if you get that, in a raffle, kind of way. And a lot of people say, oh well we’ll go on another one then ’cause, eight to ten weeks we can do that, so we had a lot of problems with that especially around this area, with people didn’t understand that.” PH16