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

Barriers and drivers of positive COVID-19 vaccination behaviours among healthcare workers in Europe and Central Asia: a qualitative cross-country synthesis

Abstract Vaccination uptake is essential to controlling the ongoing COVID-19 pandemic. Healthcare workers (HCWs) play a critical role in receiving, recommending and delivering COVID-19 vaccination. Understanding the specific influences on each behaviour enables the development of targeted and tailored interventions to improve vaccination uptake. This paper presents a qualitative synthesis of HCWs’ individual and context barriers and drivers to these three vaccination behaviours across 10 countries in Europe and Central Asia. Qualitative data from interviews and focus group discussions with 378 HCWs between December 2020 and March 2022 were synthesised and organised by four COM (capability, physical and social opportunity, motivation) factors. Differences by stage of COVID-19 vaccine roll-out (in preparation, early and late delivery) were explored. Receiving vaccination related to all four factors. Recommending vaccination mostly related to capability and motivation. HCWs were generally well-informed by official sources and viewed vaccination as the way to end the pandemic, acknowledging their important role in this. Colleagues, family and friends were positive influences on personal vaccination decisions. However, knowledge gaps were evident, particularly amongst nurses who relied on (social) media. Concerns about safety and effectiveness, often connected to knowledge gaps, were heightened by the accelerated timeline for COVID-19 vaccine development and approval. This impeded some HCWs’ motivation to receive and recommend vaccination even in the later roll-out countries. Delivering vaccination was facilitated by support from public health organisations, teamwork and service re-organisation, more evident amongst later roll-out countries. Ongoing high workloads, stress and burnout hindered delivery. Complex and inter-related factors affecting HCWs’ vaccination behaviours were identified. These insights should inform the design of multifaceted interventions (e.g., communication skills training, management support for HCWs’ mental health, and engaging them in decision-making for service redesign); not only for COVID-19 vaccination as it is integrated into routine services but for routine immunization as a whole

Using behaviour change theory to train health workers on tobacco cessation support for tuberculosis patients: a mixed-methods study in Bangladesh, Nepal and Pakistan

Background Low- and middle-income countries (LMICs) are disproportionately impacted by interacting epidemics of tuberculosis (TB) and tobacco consumption. Research indicates behavioural support delivered by health workers effectively promotes tobacco cessation. There is, however, a paucity of training to support LMIC health workers deliver effective tobacco cessation behavioural support. The TB and Tobacco Consortium undertook research in South Asia to understand factors affecting TB health workers’ delivery of tobacco cessation behavioural support, and subsequently developed a training package for LMICs. Methods Using the “capability, opportunity, and motivation as determinants of behaviour” (COM-B) framework to understand any issues facing health worker delivery of behaviour support, we analysed 25 semi-structured interviews and one focus group discussion with TB health workers, facility in-charges, and national tuberculosis control programme (NTP) staff members in each country. Results were integrated with findings of an adapted COM-B questionnaire on health worker confidence in tobacco cessation support delivery, administered to 36 TB health workers. Based on findings, we designed a guide and training programme on tobacco cessation support for health workers. Results Qualitative results highlighted gaps in the majority of health workers’ knowledge on tobacco cessation and TB and tobacco interaction, inadequate training on patient communication, insufficient resources and staff support, and NTPs’ non-prioritization of tobacco cessation in all three countries. Questionnaire results reiterated the knowledge deficits and low confidence in patient communication. Participants suggested strengthening knowledge, skills, and competence through training and professional incentives. Based on findings, we developed an interactive two-day training and TB health worker guide adaptable for LMICs, focusing on evidence of best practice on TB and tobacco cessation support, communication, and rapport building with patients. Conclusions TB health workers are essential in addressing the dual burden of TB and tobacco faced by many LMICs. Factors affecting their delivery of tobacco cessation support can be identified using the COM-B framework, and include issues such as individuals’ knowledge and skills, as well as structural barriers like professional support through monitoring and supervision. While structural changes are needed to tackle the latter, we have developed an adaptable and engaging health worker training package to address the former that can be delivered in routine TB care