| BackgroundTobacco causes enormous burden of disease and China currently has more than 300 million smokers with over 540 million people under the risk of second-hand smoking (SHS). In 2003, China ratified the World Health Organization "Tobacco Control Framework Convention" which requires all indoor public places/workplaces, public transportation and other possible outdoor public places to be'smoke-free'. Being healthcare institutions, hospitals at different levels are bound to have essential roles in developing and implementing smoke-free policies. However, tobacco control efforts in China's hospitals are far from optimistic. There are many ways to evaluate the tobacco control efforts in hospitals, but existing researches mainly focusing on quantitative methods. Therefore, it is necessary to explore the strength and weakness when combining the use of both quantitative and qualitative approaches to evaluate tobacco control programs being practiced in hospital under a triangulation view.ObjectivesTo evaluate the tobacco control efforts in hospitals using quantitative and qualitative methods, to find out problems and challenges when conducting tobacco control activities from multiple prospectives. To provide practical recommendations on creation of'smoke-free hospital' nationwide. MethodsThis study conducted with triangulation view:Evaluation on tobacco control programs carried out at hospitals in 40 cities and counties where quantitative research methods were adopted. We used Pre-and Post-program designing method which divided the hospitals into general intervention group and another one with in-depth intervention. Doctors, nurses and patients were surveyed before and after the intervention program being carried out, and asked about knowledge, attitudes, smoking behavior and SHS exposure on related tobacco issues. Smoke ban policies were reviewed and field observations of smoking phenomenon were conducted. Data were converted and analyzed using Statistical Analysis System (SAS 9.1 for Windows; SAS Institute Inc., Cary, NC, USA). Qualitative research methods were adopted when evaluate six hospitals in Chongqing. Field observations, interviews, particle matters (PM2.5) monitoring methods were used to find out smoking phenomenon, difficulties and related factors. Qualitative and semi-quantitative methods were used in analyzing data being gathered.Results1. Data related to the evaluation on hospitals in 40 cities and counties included a total number of 9504 eligible interviewees, aged 18-69, participated in the surveys and were analyzed.95% of the doctors,94% of the nurses and 80% of the patients were aware of the smoking-related knowledge during baseline, general intervention and in-depth intervention stages, respectively. The change did not show statistical significance before and after intervention.When asked about the risk of SHS risk (Those who know all:Breathing second-hand smoke puts people at increased risk for heart disease; Women who live with smokers are at more at risk for lung cancer than who women who do not live with smokers; Children who live with household members who smoke are more likely to get sick with respiratory infections or asthma than children whose family members do not smoke), the awareness rate was relatively low. The proportions of doctors who knew all the three questions were 73.75%,80.41%, and 83.67% at baseline, general and in-depth intervention, respectively. When comparing data from general intervention versus baseline, the adjusted odds ratio (AOR) was 1.51 and the AOR of in-depth intervention versus baseline was 1.87. With regard to nurses, the proportions were 74.74%,76.35%,84.49% respectively, with AORs as 1.14 and 1.91 respectively. The proportions on patients were 39.81%,53.80%,58.04%, with AOR as 1.73 and 2.11, respectively.When asked about whether hospitals, schools, offices, public transportation, smoking should be totally banned, the proportion of those agreed among doctors in the baseline, general intervention and in-depth interventions were 61.59%,63.64% and 68.35% respectively, with AORs at general intervention versus baseline as 1.13 and in-depth intervention versus baseline as 1.43. In terms of data from the nurses, the proportions were 66.36%,58.52% and 70.64%, with AORs as 0.79 and 1.31, respectively. The proportions for patients were 48.58%,54.21% and 56.95%, with AORs as 1.26 and 1.45 respectively.The prevalence of smoking among both male doctors and male nurses was still at a high level. However, the prevalence from the hospitals receiving in-depth intervention hospitals was relatively low, but still reached 40%. Prevalence of smoking among male patients did not significantly change before and after the intervention program with the prevalence rates at baseline, general intervention and in-depth intervention stages were 57.95%,61.19% and 59.54% respectively.Through our study, we noticed that the exposure rate to second-hand smoking had decreased. Exposure rate for doctors had a significant decrease from 48.88% to 35.01% in the hospitals which in-depth intervention had been carried out, with the AOR of in-depth intervention versus baseline as 0.55. Regarding exposure rate in nurses, hospitals with in-depth intervention reduced from 47.29% to 39.92%, with AOR as 0.74.At baseline survey,47.9% (57/119) of the hospitals had developed smoking-banned policies. After the general intervention program,59.6% (31/52) of the hospitals had developed related policy versus 84.9% (45/53) of the hospitals where in-depth intervention had been carried out. Proportion on the'no smell of smoking'index increased dramatically from 36.1% at baseline to 92.5% at the hospitals with in-depth intervention (χ2=46.75, P<0.0001). The proportion of'no butts of cigarette on the ground' increased from 15.1% to 75.5%(χ2=59.75, P<0.0001) and the proportion on'nobody was observed smoking' increased from 27.7% to 81.1%(χ2=42.40, P＜0.0001). The proportion of dissuading the smokers from smoking increased from 22.1% to 51.6%(χ2=9.4709, P= 0.0021).2. Results from the evaluation on six hospitals in Chongqing:strength and intensity of tobacco control efforts were different across the hospitals. Smoking in hospitals was not completely eliminated but improvement had been made after the tobacco control measures were taken. Important changes include the following facts:the establishment of the Tobacco Control Leading Group; policy-making on smoke ban in the hospitals, adding or updating no-smoking signs elsewhere inside the hospitals and launching health education campaign etc.Challenges still existed when trying to make the hospitals'smoke-free'which would include the following points:importance of tobacco control had not been fully recognized by leaders of the hospitals, system regarding reward and punishment on Tobacco Control was difficult to implement; plans on making the indoors totally banned from smoking were difficult to implement in many areas, like toilets, stairwells and lounges; Tobacco Control Supervisors had limited roles to play; only few staff working on dissuading the smokers from smoking; lack of effective cessation treatment at the related'cessation clinics' making the healthcare workers difficult to play their roles.ConclusionsAlthough smoke-free hospitals had been developed and some achievements made, smoking behaviors still existed in the hospitals. Barriers and challenges related to the implementation of a total-banned smoking program in the hospitals would mostly come from patients, their families and the employees of the hospitals. Qualitative research methods are seldom used. Findings from this study discovered the difficulties on how to develop a smoke-free hospital and elucidation on the major reasons for the adoption of different methods would provide new directions for further studies of its kind. Health administrative departments should play a more active role in tobacco control programs and the hospitals should enforce the implementation of smoke-free policies. A variety of methods should be used to evaluate the effects in creating the smoke-free hospitals.
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