Recruitment begins!

By Ani Ginosyan

Educational materials the 2010 clinical trial participants had

Yesterday I recruited participants for my focus group discussion with the help of Arus Harutyunyan, MD, MPH.  Arus is part of the tobacco control team at AUA, and she was instrumental in familiarizing me with the database and offering me advice, support, and encouragement throughout my time at the AUA.  Recruitment was a bit of a challenge due to too many people rejecting us.  I was using a database of 250 mothers who had at least one child 10 years old or younger. Their contact information was obtained from several clinics in Yerevan.

In the year 2010, a part of the 250 participated in an intervention to help them reduce their children’s exposure to secondhand smoke and the other half were classified as the no intervention control group. We started recruitment for piloting our focus group discussion guide by initially contacting the intervention group participants.  Most people refused to participate due to being very busy taking care of their children, working, or not wanting to travel to the site. Some wanted to participate; however, they later called back and told us they cannot do so because their husbands got mad at them when they discussed the topic with them. A few of them said that they don’t see a point in participating because everyone in their home smokes and they don’t feel anything is going to change that.  Several people still agreed to participate and it was a fruitful discussion that helped us target our focus group discussion questions more and learn about people’s perspectives.

The recruitment process has been challenging, but very interesting at the same time. People at times report to me on the phone that their husband has put in a lot of thought ever since the intervention, and they have now quit smoking entirely to protect the health of their family. Other people report absolutely no changes in their family’s smoking habits, and they are not interested in coming in for our focus group discussion because they don’t see a point in it. Most people fall in the middle of the spectrum where during the intervention, the topic of smoking and passive smoking was discussed in the family extensively and the smokers took extra precaution to always go outside to smoke during the time of the intervention. However, everything was slowly forgotten and people went back to their old habits after the intervention was over.  One goal in our focus group discussions has been to find out the situations in each family, and what can be done in order to make the positive outcomes last longer or better yet become permanent.Over the past week, I have had a great time conducting the focus group discussions as it gives me the opportunity to talk to people and learn about their unique experiences and challenges regarding the smoking problem in their families.  The majority of our study participants are mothers who understand and care about the negative health effects of second hand smoke and are proactively trying to make changes in their household regarding smoking.  One challenge that I observed, but was not mentioned by any mothers is the fact that the man (husband or father-in-law) is the main decision maker of the home and they don’t tend to take the woman’s words seriously when it comes to secondhand smoke.  When I asked them what is the biggest challenge you face in ensuring your kids are never exposed to secondhand smoke, none of the women identified this as a challenge; however, from hearing their stories, it became evident that this is a problem in many households.   Some husbands and/or father-in-laws don’t believe that secondhand smoke can be harmful or they realize it but refuse to take it seriously. Others want the children to get used to the smoke from a very young age.

All prepared and waiting for focus group
participants to arrive.  

Overall, it has been fulfilling to hear people say that as a result of participating in the clinical trial, the smokers in their household have quit, reduced their smoking, or they only smoke outside in an effort to protect the kids. Participants were very happy to be part of the program and wished that we would be able to reach more families and have more such programs in the future.

It is better to focus on keeping the children away from smoke and ensuring they don’t become smokers in the future

 Most moms tell us that they have given up trying to have their husbands quit smoking and they are now focusing on trying do everything possible to reduce their children’s exposure to secondhand smoke inside the house.  They also try to educate the kids to ensure they don’t become smokers in the future.  Most people I have spoken to told me that they have benefited from the intervention conducted by the AUA Tobacco Control Team. Some people have told us their husbands have quit because of the program. People have learned a lot in general about secondhand smoke and its health effects.  There have also been instances where people have told me that the program did not help them and their family members smoke the exact same way as before.  In most of these families, there is usually an elder (father-in-law) who does not see secondhand smoke harmful for health, and it is nearly impossible to reason with him or convince him. Most people note that addiction is a huge reason their husbands are not able to quit.  They also highlight that stressful jobs, long work hours, or not having a job at all are all factors that contribute to smoking and don’t allow their husbands to quit smoking.

Some mothers brought along their kids and
we kept them busy by having them make
“No Smoking” signs 
Most mothers said that their husbands are aware of the negative health effects of smoke on their children; however, it is not convenient for them to go outside all the time. They get home in the evening after a long work day and they want to rest for a few hours and be able to smoke in the house instead of going out every time they need to smoke.  All wives have been very supportive when their husbands have tried to quit or reduce their smoking habits.  From the focus group discussions, I realized that people in general, and especially the smokers, don’t believe that secondhand smoke can have negative health outcomes. It is not something that they see right away, and so they don’t believe anything really bad can happen. One dad I interviewed said that he needs to see proof to believe that secondhand smoke is bad for his kids. He said that just like they show pictures comparing lungs of smokers versus nonsmokers, they need to show such proof for secondhand smoke exposure. He noted that only then will he believe it is bad for his kids and not smoke by them under any circumstances.

In order to collect more data during the short time period that I have left in Armenia, we had decided to use a mixed methods approach where we do focus group discussions in addition to individual interviews. It has worked pretty well as I am able to schedule people whenever it is convenient for them instead of giving them a fixed date and time that they need to be in our office.  It has been a good experience to talk to people and learn their stories both in individual and group settings.