Knowledge and Attitudes of Bar Attendants towards Second-Hand Smoke in Nyarugenge District, Rwanda

Report has shown that there is an increase of respiratory disease among bars attendants over time whereby in 2011, 32% of bars attendants reported respiratory diseases. The purpose of this study was to assess the knowledge and attitudes of bar attendants towards second-hand smoke (SHS) at work place in Nyarugenge District, Rwanda. This was a cross-sectional study using mixed methods of both qualitative and quantitative. A total of 384 bar attendants participated in the study. Quantitative data were analyzed using SPSS version 21 while qualitative data were analyzed using thematic analysis. Descriptive analysis using frequency and percentages was computed. he qualitative data was analyzed using thematic analysis. The majority of respondents (66.4%) were within the age group of 28-37 years, 60.2% of respondents were males, 60.9% of respondents were illiterate, and 57.3% of respondents were single at the time of data collection.The majority (78.6%) of the study respondents knew that Smoking is dangerous to human health. The cited consequences of SHS include air pollution that enter the respiratory system and damage the lungs, dizziness and others. All respondents agreed that people who smoke should not be allowed to smoke in public places. Improving bar attendants’ access to health education on SHS and encouraging continuous and constant exposure would significantly increase the knowledge and attitude levels of bar attendants towards SHS.


Background
Smoking increases the risk of non-communicable diseases, not only to smokers but also for second-hand smokers. Second-hand smoke may adversely affect health and aggravate illness. A recent report of World Health Organization (WHO) shows that tobacco kills more than eighty million people each year, the report underlined that around 1.2 million of those deaths are the result of non-smokers being exposed to second-hand smoke. The same report show that 1.3 billion tobacco users live in low-and middle-income countries [1].
Every year, millions of people die from tobacco use and several hundred thousand die from exposure to second hand smoke (SHS). Families, industries and nations suffer from these preventable deaths. The World Health Organization (2005) indicates that more than 5 million people die annually from tobacco use and more than 600 000 die annually from second hand smoke exposure. It is disturbing that such a large number of people (600 000) die due to unintentional smoking. Passive smoking, which is unintentional smoking, is the inhalation of smoke, called second hand smoke (SHS) or environmental tobacco smoke (ETS), by persons other than the intended "active" smoker.
Passive smoking occurs when tobacco smoke permeates any environment and is inhaled by people within that environment [2]. Recent studies have shown that, of all public places, restaurants and bars have the highest SHS concentrations. Restaurants and bars are frequently visited by the public for entertainment [3].

Socio-Demographic Characteristics
A total of 384 respondents participated in the study giving a response rate of 100%. The results are presented in frequency tables and graph forms.

Smoking Related Factors
The distribution of the selected smoking related factors among bar attendants is shown below.
As indicated in have high knowledge about SHS. The participants of FGD 2 said that: "All people know the consequences of second hand smoke. There are bad consequences to people who approach the smoker. These include air pollution that enter the respiratory system and damage the lungs, dizziness and others".
Other participants of FGD 3 also said that: "Many times, people who drink beer also smoke tobacco. This is what cause second hand smoke in this bar. In addition, both beer and tobacco are at the level of drugs. However, there are no law against tobacco and measures taken for people who smoke".
About Preference to work in a smoke-free environment, the participant of FGD1 said that: "Human nature is what makes a person to be glad with working in a certain place. For instance, if a person is a smoker, no problem for him/her to work in a smoke free environment, but if he/she is not, he/she cannot be content of the job except that he/she needs money".
The same was supported by FGD 2&3.

Attitude of Bar Attendants Towards Second Hand Smoke in Nyarugenge District
As indicated in All the FGDs comments supported the motion.
About perception on indoor and/or outdoor public places should be smoke-free, the participant of FGD 2 said that: "What is known is that it is forbidden to smoke in public where many people are meeting. But, no problem if those who continue smoking go away or out of the bar". FGD 1&3 comments were similar to key.
The participant of FGD 3 said that: "The Ministry of Health should look into this case of tobacco smoking and takes appropriate measures. In order to preserve the health of people, the Ministry of Health should prevent from buying and selling tobacco; increase taxes for sellers of tobacco, or stop industries of tobacco carrying on a function". FGD 1&2 comments were similar to that of FGD 3.

Discussions
Smoking also has an environmental impact due to second hand (passive) smoking [7]. The impact of smoking is not limited on the smokers, but it can spread to affect the non-smokers as well. Second hand smoking has an impact on birth outcomes represented in low birth weight [8], and contribute significantly to respiratory tract infections in infants [9].
Globally, improving knowledge, attitude, and practice (KAP) is considered an effective solution to reducing exposure to SH [10]. We found that the majority (78.6%) of the study respondents knew that It is proven that those who are not smoking have better tobacco smoking related knowledge than those who are smoking. This may be due to several reasons and one of them is education, where the more people have education, the more they will tend to avoid SHS.
People, regardless of smokers or non-smokers are not aware of the public smoking policy being enforced in the country. The lack of knowledge among smokers about the effect of SHS expose to non-smokers. The attitude of people played important role to avoid from SHS exposure. In our study, the different study respondents suggested to design the smoking area in order to avoid the negative impact of tobacco smoking in public places.

Conclusions and Recommendations
Bar attendant demonstrated good knowledge about SHS health consequences but translating these knowledge into practices were found poor, the study also concludes that half of the study participant has positive attitude on SHS.
There is a need of interventions to rise up the knowledge and attitude on SHS among bar attendants. Improving bar attendants' access to health education on SHS and encouraging continuous and constant exposure would significantly increase the knowledge and attitude levels of bar attendants towards SHS.