Of 50 women invited, 21 accepted the invitation to interview across the four pilot trial waves; one scheduled participant did not attend; the remainder were not available during the interview timeframe (one to two weeks post final programme session). All CFs (N=8) were also interviewed. A total of 26 interviews were conducted: Wave 1: 4, (2 CFs); Wave 2: 8, (2 CFs); Wave 3: 7 (includes two separate CF interviews); Wave 4: 7 (2 CFs).
Figure 1 displays the overall coding frame for the qualitative results, categorised into a) ‘Programme level’ and b) ‘Trial level’ results following the MRC process evaluation framework.
Category I. Programme level results
Two main themes were identified under this category: NRT and group support.
Theme 1. Nicotine Replacement Therapy (NRT)
Subtheme 1.1. Cost of and access to NRT
In Ireland, patients entitled to the General Medical Scheme (GMS) are eligible for low or no cost prescriptions (48), while non-GMS ‘private’ patients typically pay directly for NRT. In the current trial the cost of NRT for non-GMS patients was covered by the Irish Cancer Society. This was noted and appreciated by the participants.
W4–P049: It was great [free NRT], yeah, yeah, I found it fantastic. It was great to get it.
Participants who were GMS-entitled were required to obtain an NRT prescription before it could be dispensed without charge. In some circumstances this created a problem because of a lack of available general practitioner (GP) appointments and could also result in the participant feeling uncomfortable when engaging with the dispensing pharmacy.
W4–CF 2: … one of the ladies said sure ‘I can’t even get an appointment; it takes 3 weeks to get an appointment’…
W4–CF 1: And then when the pharmacists confronted the ladies about the prescription they kind of were uncomfortable that they felt em they were being put under a bit of pressure to get the prescription off their doctor and they were stressing over it. One girl was very stressed about it, she was actually nearly crying here one night because she said she was left sitting for over half an hour in the pharmacy and… She felt like she was under complement to them, you can’t have that when you’re going through a programme like this, it’s just too stressful.
Subtheme 1.2. Views, beliefs, and opinions about NRT
Despite positive feedback from participants who were able to access NRT for free, there were negative views about the side effects of NRT, including taste and irritability relating to fluctuations of mood.
W3–P0005: I never felt sick from cigarettes. It’s (the patch) making me sick and sometimes I’m afraid that when I’m putting the patch on I’m scared that this is going to make me sick.
The CFs understood that women may have concerns about NRT side effects either from previous personal experience or from listening to friends’ and family members’ experiences. Participants also expressed concern about the potential for NRT dependence, and the concept of swapping one ‘addiction’ for another while not addressing the habitual aspects of smoking:
W4–P065: Yeah, and I’m still having to use the nicotine replacement there now and I’m still dependent on that. I’d had a big worry about getting addicted to this (inhaler)…I reach for it, just like I used to reach for a cig.
Subtheme 1.3. Role of the community pharmacist
A key aspect of the WCQ2 trial was to bring clarification on NRT and its role in smoking cessation. To this end, efforts were made in preparatory phases to identify one local community pharmacy in each study area willing to dispense and provide support to the women on their quit attempts.
W1–P0007: You see the pharmacist coming in like giving an account of what everything does and how you come off it and how you cut down and all like that would be a big help. Yeah, he was very good, his attitude was really good, and he couldn’t have been more helpful like do you know. So that was another support there which was really good.
The community pharmacists involved were going beyond traditional roles of dispensary pharmacy and providing additional support to the women when they presented at the pharmacy for their NRT. During the trial, some CFs actively encouraged participants to link with pharmacists if they were struggling with their quit attempt or lulls in motivation.
W2–CF1: ….they had their moments and they’d arrive in the door to him…And he’d [pharmacist] a little room to the side and he’d take them in and talk it through with them.
Pharmacists were providing participants with additional brief interventions that may have augmented the group sessions. However, not all community pharmacists were that supportive. Pharmacists were invited to attend a group session to explain NRT, however, not all were willing to do this.
W4–CF2- No the pharmacist didn’t come in because they couldn’t, they didn’t want to stand up and talk in front of people.
Theme 2. Group Support and Community Facilitators
Subtheme 2.1. Positive effects of peer support – modelling behaviours for self-efficacy
Participants noted the positive aspect of role-modelling in peer support, which demonstrated that stopping smoking was possible.
W3–P0005: Going to the meetings…you’re more aware of where you were smoking, who was around you…and then by listening to the other people, how they did it, you pick up all the little knick knacks like you know.
The ability to relate and to recognise oneself within a group is a core tenet of why group support works. Trust and compatibility underpin this and the related concept of learning from others.
W2–P0041: Well, I found when I came first that everybody was the same as me…You only just felt we’re all here together on the same wavelength…. Normally when I give up the cigarettes, I feel that somebody has after gone from my life, I’m after losing a friend, I’d be pining but this time I says, ‘no I’m not losing a friend’. So, something worked in the head.
Participants’ spoke of group support in terms of building capacity by increasing their skills, self-efficacy, and support for maintaining abstinence. The group support they received strengthened and reinforced their intentions to cease or decrease smoking. Participants often provided informational support to one another, offering advice and suggestions about smoking cessation strategies through an informal exchange process.
W1-P0040: …that lady she taught me one thing that I didn’t know, and I taught her something that she wouldn’t have known so that’s the way that it went around in the meetings, we all found out something different to help us and if one fell off the wagon we’d turn around and say, ‘don’t worry about it’.
Subtheme 2.2. Peer teaching, learning and potential for wider message dissemination
Participants reflected that their relationships with members of the group became a part of their motivation to quit:
W3-P0003: I feel like if I went back smoking I’d be letting them down… it’s not about letting myself down, it’s about letting them down.
Through the shared experience, participants demonstrated empathy towards one another. This went deeper than the standard ‘common bond in common disease’, as outlined here:
W3–CF1: …it became a nice comfortable space to be in and I think that’s what encouraged them to come back. Yes, and for the weeks where they were feeling a bit vulnerable and a bit low and a bit judgemental and self-berating, the other women in the group expressed their encouragement and compassion.
Related to this was the potential for broader smoking prevention and cessation message dissemination via the social networks of women in the trial. Twenty-four women in the intervention arm provided social networking data and between them made a total of 93 nominations, an average of 3.9 nominations for each WCQ participant, which shows potential for message diffusion. The actual extent of message diffusion was extremely high at 97% (n=90), hence trial participants were speaking to people in their network about the programme (see Additional File 3). Finally, perception of impact was noted in nearly two thirds (61.1%, n=55) of the people spoken to.
Subtheme 2.3. Importance of non-judgemental interactions
Participants felt the support group was a non-judgmental environment where they felt understood, in contrast to attitudes some had encountered outside from both loved ones and healthcare professionals alike.
W2-P0026: …because I think they understood what you were going through you know what I mean, people at home were great and they were supportive but they thinking after a day or two you should be over it you know whereas this they knew what you were going through you know so we kind of all went through it together.
Most participants expressed that the group sessions were a very supportive, encouraging environment that helped motivate them to persist with their quit attempt.
W1-P0004: do you know, it’s a long-term thing, …it’s still one day at a time ok but I feel like there’s a spell broken, that’s the only way I can explain it, that smoking, or addiction is a spell, it’s like being in a spell and that’s broken, which is huge.
Subtheme 2.4. Trust and confidentiality
The trust that was built amongst group members facilitated feeling psychologically safe enough to be vulnerable and honest within a group setting. A sense of mutual trust among group members increases the effectiveness of a group (49).
W4–P010: We were quite an open group. The kind of type of women just wearing our life on our sleeve and just say what we had to say.
Women reported the freedom to discuss their general stress in their lives and the stress experienced vis-a-vis making a quit attempt.
W2-P0011: Yeah I didn’t hide it because it was so private. I wasn’t going to lie and say everything was great because we all had a good rant every now and again. ….somebody was going through the same, they were really close to tears, and just to see that and go, “right I’m not cracking up, I’m not losing my mind. It’s normal”.
Category II. Trial level results
This category of results comprised two main themes: data collection methods and measures, and fidelity.
Theme 3. Data collection methods and measures
Subtheme 3.1. Provision of a salivary sample.
Biochemical verification of smoking status is expected in smoking cessation trials to evaluate intervention effectiveness. We asked participants their experience of providing a salivary sample for this biochemical validation. Some participants found the process acceptable.
W1–P0040: That was grand, but it got stuck in your mouth trying to get it wet. Me mouth was lovely and wet before it went in and then all of a sudden it just dried up and I wasn’t sure whether it was wet enough or not. No, it wasn’t a problem because it has to be studied.
However, others reported that the process of providing the salivary sample was very challenging.
W4–P010: It was awful. It took me ages to get a bit [of saliva]. It [the cotton swab] was very big for my mouth.
Subtheme 3.2. Literacy levels.
Literacy levels among participants were explored both in relation to the WCQ2 participant intervention booklet, a standard part of the programme, and paperwork associated with the trial.
W3-P0013: The only thing that I would get you to look into is that with the writing. Too much papers, too much writing in. And I think like that for people that want to give up the cigarettes but can’t write and you might get some that can’t read and it’s embarrassing for them and that would turn them off then in going to the sessions. That’s the main thing.
W1–P0040: I can’t spell for diamonds, so I found it difficult if I was to write in it. One question you could put at the start [is to ask] if you have a problem filling out the forms or if you need help to complete or break down the [writing], we have no problem doing that.
The CFs were largely experienced in delivering the programme in SED communities so they were familiar and sensitive to low literacy. One CF had a background as a literacy tutor in a different role and she shared her insights:
W3–CF 2: You can see that straight off when you go into a room because there’s the tell-tale signs, people are forgetting their glasses and forgetting their journals the second week…. when they think of the ‘We Can Quit’ programme they don’t realise about the journal and that can be very off-putting when a person comes in and they’re handed a journal. They can see that it’s like a workbook as well and that there’s writing to be done. And often like as we say the first time at any class, we always stress that you know this journal is yours and it’s not for us to see and what you do in it is your business…
Subtheme 3.3. Use of repeated measures.
Questionnaire data were collected at baseline, and at 12-weeks and 6-months post-intervention. Women reported satisfactory understanding of the necessity for multiple data collection timepoints.
W4 – P049: Not at all, no, no with the help that I was after receiving I was more than willing, more than willing whatever I had to what I had to do to answer the questions. It’s payback.
This willingness extended to providing a biological sample on more than one occasion, with one woman stating:
W3 – P004: I wasn’t mad about giving the sample again because my mouth gets very dry but the girl [research assistant] explained why I needed to do it again – so I did it.
Theme 4. Fidelity
Subtheme 4.1. Tailoring sessions to checklist instead of intervention manual
Fidelity to the intervention manual was assessed by self-report methods through a checklist of intervention sessional components, completed after each session by the CFs (27). Generally, CFs gave a positive reaction to the fidelity checklist:
W1–CF 1: The evaluation is good because I was using that and then I’d turn it into my own little thing reminders you know the evaluating at the end of every group.
There was a sense from the CFs that the use of the fidelity checklist went further than just a behavioural prompt for sessional content delivery and was discussed in terms of conscious efforts to change delivery of sessions.
W2–CF 2: You kind of are watching a lot more…..because we had to chart everything and you were more inclined to try and stay on course. Sometimes in a group you go in with a lesson plan, but it goes totally out the window because somebody starts to talk about something else and it takes off on its own. But this time around, I made much more of an effort to stick to the plan.
One CF noted that for her the presence of the fidelity assessment processes meant that she felt she was being ‘watched’ by the research team.
W2–CF 1: I was following because I did feel you know our own diary, our community diary that was very much a kind of a big brother watching that you need to do those things.
Subtheme 4.2. Acceptability of direct or indirect methods of fidelity assessment
Hypothetical scenarios were presented to all interviewees regarding alternative fidelity assessment methods. These included direct observational methods (e.g., having a researcher present in the room during group sessions) or indirect methods (e.g., sessions audio recorded and assessed at a later stage by the research team). There were some concerns raised by CFs that indirect observational recording could threaten the privacy of session, and whether an audio recording could interfere with the dynamic of the session:
W2–CF 2: I wouldn’t say record it because it’s personal to the women taking part. I wouldn’t mind them watching and that, but I wouldn’t fancy it being recorded.
W2–CF 1: Yeah, the watching wouldn’t bother me, but I think it would change the dynamic of the room if it was recorded.
There was little concern about having an independent observer changing the group dynamic from other CFs.
W3–CF 2: I certainly wouldn’t have an issue; I can understand what the research is for. I wouldn’t have an issue. You would have an earful with this group anyway! But em I don’t think that would have stopped anybody [from speaking].
This was underscored by one participant who recalled that during one session the community pharmacist was present and that had no impact on the direction or tone of the session.
W4–P00027: No because I remember when the pharmacy guy came in he was there for one session and nobody batted an eyelid. It was just like he was there on the sidelines before he went off speaking. So no, it was fine.
The issue of prior knowledge and consent relating to fidelity measurement was echoed amongst programme participants.
W2–P0006: I wouldn’t have an issue with that as long as you were giving advance notice and there was real clarity around it.
This pragmatic, democratic and altruistic approach to fidelity was also shared amongst women in terms of indirect audio recordings. Alongside this an additional key issue around the confidentiality and safe keeping of recordings came into play.
W2–P0001: So long as it was falling into the right hands and it was for research and was going to help people and maybe make the course better to help other people give up the cigarettes then [I’ve] no problem with it. It would just show what is discussed in the group and the recordings would show that the discussions that take place are invaluable.
This altruistic consideration recognised fidelity as a part of research evaluation of the programme itself.
W2–P0015: I don’t think so, no. Do you know it’s for research like. It’s brilliant like. Obviously other women are going to you know gain from what we’ve done, so if someone could save someone do you know it’s worth it like?