Scaling up tobacco cessation within TB programmes: findings from a multi-country, mixed-methods implementation study

BACKGROUND: Brief behavioural support can effectively help tuberculosis (TB) patients quit smoking and improve their outcomes. In collaboration with TB programmes in Bangladesh, Nepal and Pakistan, we evaluated the implementation and scale-up of cessation support using four strategies: (1) brief tobacco cessation intervention, (2) integration of tobacco cessation within routine training, (3) inclusion of tobacco indicators in routine records and (4) embedding research within TB programmes. METHODS: We used mixed methods of observation, interviews, questionnaires and routine data. We aimed to understand the extent and facilitators of vertical scale-up (institutionalization) within 59 health facility learning sites in Pakistan, 18 in Nepal and 15 in Bangladesh, and horizontal scale-up (increased coverage beyond learning sites). We observed training and surveyed all 169 TB health workers who were trained, in order to measure changes in their confidence in delivering cessation support. Routine TB data from the learning sites were analysed to assess intervention delivery and use of TB forms revised to report smoking status and cessation support provided. A purposive sample of TB health workers, managers and policy-makers were interviewed (Bangladesh n = 12; Nepal n = 13; Pakistan n = 19). Costs of scale-up were estimated using activity-based cost analysis. RESULTS: Routine data indicated that health workers in learning sites asked all TB patients about tobacco use and offered them cessation support. Qualitative data showed use of intervention materials, often with adaptation and partial implementation in busy clinics. Short (1–2 hours) training integrated within existing programmes increased mean confidence in delivering cessation support by 17% (95% CI: 14–20%). A focus on health system changes (reporting, training, supervision) facilitated vertical scale-up. Dissemination of materials beyond learning sites and changes to national reporting forms and training indicated a degree of horizontal scale-up. Embedding research within TB health systems was crucial for horizontal scale-up and required the dynamic use of tactics including alliance-building, engagement in the wider policy process, use of insider researchers and a deep understanding of health system actors and processes. CONCLUSIONS: System-level changes within TB programmes may facilitate routine delivery of cessation support to TB patients. These strategies are inexpensive, and with concerted efforts from TB programmes and donors, tobacco cessation can be institutionalized at scale

Health worker and patient views on implementation of smoking cessation in routine tuberculosis care

Böckmann M, Warsi S, Noor M, et al. Health worker and patient views on implementation of smoking cessation in routine tuberculosis care. NPJ primary care respiratory medicine. 2019;29(1): 34.Smoking worsens tuberculosis (TB) outcomes. Persons with TB who smoke can benefit from smoking cessation. We report findings of a multi-country qualitative process evaluation assessing barriers and facilitators to implementation of smoking cessation behaviour support in TB clinics in Bangladesh and Pakistan. We conducted semi-structured qualitative interviews at five case study clinics with 35 patients and 8 health workers over a period of 11 months (2017-2018) at different time points during the intervention implementation phase. Interviews were conducted by trained researchers in the native languages, audio-recorded, transcribed into English and analysed using a combined deductive-inductive approach guided by the Consolidated Framework for Implementation Research and Theoretical Domains Framework. All patients report willingness to quit smoking and recent quit attempts. Individuals' main motivations to quit are their health and the need to financially provide for a family. Behavioural regulation such as avoiding exposure to cigarettes and social influences from friends, family and colleagues are main themes of the interviews. Most male patients do not feel shy admitting to smoking, for the sole female patient interviewee stigma was an issue. Health workers report structural characteristics such as high workload and limited time per patient as primary barriers to offering behavioural support. Self-efficacy to discuss tobacco use with women varies by health worker. Systemic barriers to implementation such as staff workload and socio-cultural barriers to cessation like gender relations, stigma or social influences should be dealt with creatively to optimize the behaviour support for sustainability and scale-up

Study of Serum Uric Acid Level in Acute Coronary Syndrome in Nepalese Subjects

At present, cardiovascular diseases are global health problems responsible for 17.3 million deaths per year and adding extra burden in developing countries like Nepal. Studies show that serum uric acid (SUA) can result in endothelial dysfunction which can lead to vascular disease like stroke. In this study, we determined serum uric acid levels in patients with acute coronary syndrome (ACS) and assess its risk factors. A cross sectional study was conducted in 82 patients with ACS who fulfilled the inclusion criteria included in the study and their serum uric acid level were investigated. It was found that 51 (62.2%) were males and 31 (37.8%) were females. Mean age in study population was 60.26 ± 11.34 years. Majority of the population belongs to 56-65 years age group. The mean uric acid level of our study population was 6.03 ± 1.50 mg/dl (male = 5.92 ± 1.72, female = 6.64 ± 1.53). SUA ? 7 mg/dl was maximum in 56-65 years age group and there was no association between age and SUA (P value = 0.146). Over half of the study population were hypertensive i.e. 42 (51.21%) and smoker i.e. 43 (52.43%). It showed association between SUA and ACS (P value = 0.003). Among those having diabetes, maximum have SUA ? 7 mg/dl i.e. 17 (47.22%). Among those having high cholesterol level, male have higher incidence than female with no association between T. Cholesterol and gender (P value = 0.49). The mean value of T. Cholesterol was 189.83 ± 46.81 mg/dl (male = 198.78 ± 55.19 mg/dl, female = 202.30 ± 54.92 mg/dl) with (P value = 0.52). In conclusion, the mean age of ACS patients was 60.26 years, with the peak incidence at the age of 56-65 years. The ACS had male predominance. The potential risk factors of ACS were: Age >56 years (65.83%), male sex (62.2%), dyslipidemia (35.36%, hypertension (51.2%), diabetes mellitus (43.9%), smoking (52.4%) and alcohol consumption (39%). Among these SUA significantly associated with risk factors were- Sex, Diabetes Mellitus, T. Cholesterol. There was association between serum uric acid level and ACS patients. Hypertension and smoking constitutes one of the major risk factor for ACS in study population