Potential impact of a pilot training program on smoking cessation intervention for tuberculosis DOTS providers in Malaysia

Colliding Epidemics: Research Gaps and Implementation Science Opportunities for Tobacco Use and HIV/AIDS in Low- and Middle-Income Countries

Introduction

Tobacco use is a leading cause of cancer death among people living with HIV (PLWH) worldwide, and smoking prevalence tends to be higher among PLWH. The burden of both HIV/AIDS and tobacco use is increasingly concentrated in low- and middle-income countries (LMICs), where resources to address these challenges are often limited. However, there has been limited effort to date to integrate tobacco cessation into HIV programs in LMICs.

Methods

We searched the literature (searching was conducted between October 1 and December 31, 2020) using PubMed including search terms “tobacco” and “HIV” and “cessation” over the past ten years (searching for articles published between December 1, 2010, and December 1, 2020) to identify original research studies on tobacco cessation interventions conducted in LMICs for PLWH. We also conducted an analysis of NCI-funded research grants on tobacco cessation and HIV awarded during fiscal years 2010 to 2020. Results and Discussion. Existing evidence suggests that conventional tobacco cessation treatments may be less effective among PLWH. Moreover, while substantial evidence exists to support a range of cessation interventions, most of this evidence comes from HICs and is only partly applicable to the evolving social, economic, and cultural climate of many LMICs. There is an urgent need to develop, adapt, and implement effective tobacco control and cessation interventions targeted to PLWH in LMICs, as well as to generate evidence from these settings. Implementation science provides tools develop and test strategies to overcome barriers and to integrate and scale up cessation services within existing HIV treatment settings.

Conclusion

There is a unique opportunity to address HIV and tobacco use in a coordinated way in LMICs by integrating evidence-based tobacco cessation into HIV programs.

Are they there yet? Linkage of patients with tuberculosis to services for tobacco cessation and alcohol abuse - a mixed methods study from Karnataka, India

Background

Tobacco use and alcohol abuse are associated with higher risk of tuberculosis (TB) infection, progression to active TB and adverse treatment outcomes among patients with TB. Revised National Tuberculosis Control Programme (RNTCP) treatment guidelines (2016) require the documentation of tobacco and alcohol use among patients with TB and their linkage to tobacco and alcohol abuse treatment services. This study aimed to assess the extent of documentation of tobacco and alcohol usage data in the TB treatment card and to explore in-depth, the operational issues involved in linkage.

Methods

A convergent parallel mixed methods study was conducted. All new TB treatment cards of adult patients registered under RNTCP between January and June 2017 in Dakshina Kannada district were reviewed to assess documentation. Document review was done to understand the process of linkage (directing patients to tobacco and alcohol abuse treatment services). In-depth interview of health care providers (n = 7) and patients with TB (n = 5) explored into their perspectives on linkage.

Results

Among 413 treatment cards reviewed, tobacco use was documented in 322 (78%), of whom 86 (21%) were documented as current tobacco users. Sixteen (19%) out of these 86 patients were linked to tobacco cessation services. Alcohol usage status was documented in 319 (77%) cards of whom 71(17%) were documented as alcohol users. Eleven (16%) out of these 71 patients were linked to alcohol abuse treatment services. The questions in the treatment card lacked clarity. Guidelines on eliciting history of substance abuse and criteria for linkage were not detailed. Perceived enablers for linkage included family support, will power of the patients and fear of complications. Challenges included patient’s lack of motivation, financial and time constraints, inadequate guidelines and lack of co-ordination mechanisms between TB programme and tobacco/alcohol abuse treatment services.

Conclusion

Documentation was good but not universally done. Clear operational guidelines on linkage and treatment guidelines for health care providers to appropriately manage the patients with comorbidities are lacking. Lack of coordination between the TB treatment programme and tobacco cessation as well as alcohol treatment services was considered a major challenge in effective implementation of the linkage services.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3913-8) contains supplementary material, which is available to authorized users.

Malaysian pharmacy students' intention to provide smoking cessation counseling

BACKGROUND AND PURPOSE

Malaysian National Quit Smoking Program had proposed to integrate smoking cessation counseling skills into all relevant healthcare curricula as one of its strategies to increase the number of Malaysians giving up smoking. More effective implementation of the curricula can be facilitated by further understanding the factors influencing students' intention in terms of providing smoking cessation counseling. This study, guided by Integrated Behavior Model (IBM), aimed to explore the factors which influenced pharmacy undergraduates in providing smoking cessation counseling.

EDUCATIONAL ACTIVITY AND SETTING

Following the elicitation study, the IBM-guided questionnaire was developed and distributed to students from two pharmacy schools which agreed to participate, each representing public and private institutions.

FINDINGS

A total of 387 pharmacy students participated yielding a 83% response rate. Multiple regression analysis revealed that all three, namely, attitude (23%), perceived norm (16%), and personal agency (16%) were significant predictors of students' intention. Further analysis revealed 'experiential attitude', a component of attitude as the strongest predictor. In other words, students who felt more comfortable had higher intention to provide smoking cessation counseling.

SUMMARY

An implication of this study is that tobacco-related curricula with an emphasis to enhance students' comfort level in providing counseling would be of value for these future pharmacists in terms of their intention as well as actual provision of smoking cessation counseling through the mediation of "experiential attitude" and personal agency.

Evaluations of training programs to improve human resource capacity for HIV, malaria, and TB control: a systematic scoping review of methods applied and outcomes assessed

BACKGROUND

Owing to the global health workforce crisis, more funding has been invested in strengthening human resources for health, particularly for HIV, tuberculosis, and malaria control; however, little is known about how these investments in training are evaluated. This paper examines how frequently HIV, malaria, and TB healthcare provider training programs have been scientifically evaluated, synthesizes information on the methods and outcome indicators used, and identifies evidence gaps for future evaluations to address.

METHODS

We conducted a systematic scoping review of publications evaluating postgraduate training programs, including in-service training programs, for HIV, tuberculosis, and malaria healthcare providers between 2000 and 2016. Using broad inclusion criteria, we searched three electronic databases and additional gray literature sources. After independent screening by two authors, data about the year, location, methodology, and outcomes assessed was extracted from eligible training program evaluation studies. Training outcomes evaluated were categorized into four levels (reaction, learning, behavior, and results) based on the Kirkpatrick model.

FINDINGS

Of 1473 unique publications identified, 87 were eligible for inclusion in the analysis. The number of published articles increased after 2006, with most (n = 57, 66%) conducted in African countries. The majority of training evaluations (n = 44, 51%) were based on HIV with fewer studies focused on malaria (n = 28, 32%) and TB (n = 23, 26%) related training. We found that quantitative survey of trainees was the most commonly used evaluation method (n = 29, 33%) and the most commonly assessed outcomes were knowledge acquisition (learning) of trainees (n = 44, 51%) and organizational impacts of the training programs (38, 44%). Behavior change and trainees' reaction to the training were evaluated less frequently and using less robust methods; costs of training were also rarely assessed.

CONCLUSIONS

Our study found that a limited number of robust evaluations had been conducted since 2000, even though the number of training programs has increased over this period to address the human resource shortage for HIV, malaria, and TB control. Specifically, we identified a lack evaluation studies on TB- and malaria-related healthcare provider training and very few studies assessing behavior change of trainees or costs of training. Developing frameworks and standardized evaluation methods may facilitate strengthening of the evidence base to inform policies on and investments in training programs.

Evaluating the impact of healthcare provider training to improve tuberculosis management: a systematic review of methods and outcome indicators used

BACKGROUND

Developing human resources capacity is vital for tuberculosis (TB) control in low- and middle-income countries. Although investments in TB healthcare provider (HCP) training programmes have increased, it is unclear whether these are robustly evaluated. The objective of this systematic review was to synthesize the methods and outcome indicators used to assess TB HCP training programmes.

METHODS

A systematic scoping review of publications reporting on evaluations of training programmes for TB HCPs - including doctors, nurses, paramedics, and lay health workers - was conducted through a search in three electronic databases, Google Scholar, and five websites of non-profit organizations. Data on the study location, population trained, outcomes assessed, and evaluation approach were extracted.

RESULTS

After screening 499 unique publications, 21 were eligible for inclusion in the analysis. The majority of evaluations were conducted in Africa. The most common evaluation methods were a review of patient records (n=8, 38%) and post-training interview with trainees (n=7, 33%). In terms of outcomes, more than half of the studies (n=12, 57%) evaluated knowledge acquisition of trainees, with only six (29%) assessing on-the-job behaviour change.

CONCLUSIONS

Even though more funds have been invested in TB HCP training, publications from robust evaluations assessing the impact on quality of care and behaviour change are limited.

Introducing smoking cessation to Indonesian males treated for tuberculosis: The challenges of low-moderate level smoking

There is a dearth of information about the smoking habits of people currently and formerly treated for tuberculosis (TB) in low- and middle-income countries (LMICs). In this paper we describe research carried out in Indonesia between 2007 and 2011 designed to investigate both the impact of TB-specific quit smoking messages in the TB clinic and at home, and shifts in patterns of smoking among those formerly treated for TB who continue to smoke. The results of a modest two-arm smoking cessation trial involving 87 patients undergoing Directly Observed Therapy Short course treatment (DOTS) for TB are presented. In one arm patients received a TB-specific quit smoking message delivered by doctors and a TB and smoking educational booklet and quit smoking guide. In the second, family support arm, patients also received on-going cessation messages delivered by family members trained to be DOTS supporters. The study followed patients twice during their six months of DOTS treatment and twice six months post treatment. Both arms of the study reduced rates of smoking during and following TB treatment significantly with 73% of patients in the doctor arm and 71% in the family support arm remaining quit at the end of the treatment (month 6). When complete abstinence at six months after treatment was taken as a primary outcome measure, no statistical difference was found in the effectiveness of the two arms of the intervention. Notably, 67% of higher-level smokers at baseline and 33% of low-moderate level smokers at baseline quit entirely. Many of those who resumed smoking did so at low-moderate levels (<6 cigarettes a day). Eighty-four percent of patients who quit during treatment maintained their abstinence six months after treatment, 13% resumed smoking at a low-moderate level (<6 cigarettes), and only 3% resumed smoking at a higher level. A purposeful sample of 15 patients who shifted from heavy smoking (20-40 cigarettes per day) to low-moderate levels of smoking post treatment were followed for an additional 12 months. We report on their ability to sustain lower levels of smoking and self-perceived smoking status given their dramatic reduction in cigarette consumption. This is the first study of low-moderate level smoking among patients formerly treated for TB conducted anywhere in South-East Asia.

Training Malaysian Pharmacy Undergraduates with Knowledge and Skills on Smoking Cessation

OBJECTIVE

To evaluate the feasibility of an online training module, Certified Smoking Cessation Service Provider (CSCSP), developed for practicing pharmacists to equip pharmacy students with knowledge necessary for smoking cessation counseling and to assess the changes in student knowledge and skills regarding smoking cessation following training.

DESIGN

Sixty third-year and 80 fourth-year pharmacy undergraduates (N=140) were given access to an online module, the main intervention in the study. Two linkable questionnaires were administered to assess students' preintervention and postintervention knowledge. For the third-year students, an additional role-play training component was incorporated, and student skills were assessed during week 14 with an Objective Structured Clinical Examination (OSCE).

ASSESSMENT

Preintervention and postintervention knowledge assessments were completed by 130 (92.8%) students. Sixty-six students scored above 50% for the knowledge component postintervention, compared to 13 at preintervention, demonstrating significant improvement (x2(1, N=130)=32, p=0.003). All third-year students completed the intervention, and 66.7% were able to counsel excellently for smoking cessation, scoring more than 80%.

CONCLUSION

The CSCSP online module developed for practicing professionals was found suitable for equipping pharmacy undergraduates with knowledge on smoking cessation topics. The module, along with role-play training, also equipped students with knowledge and skills to provide smoking cessation counseling.

Making a case for systematic integration of theory-based tobacco education into graduate psychiatric/mental health nursing curriculum

Tobacco use and dependence is a serious public health issue that disproportionately affects the mentally ill client population. Mental health professionals, including psychiatric/mental health advanced practice nurses (PMHAPNs), are disinclined to integrate tobacco cessation interventions into their practice, due in part, to a general lack of tobacco-related knowledge (C. Essenmacher, C. Karvonen-Gutierrez, J. Lynch-Sauer, & S. A., Duffy, 2008; A. J. Molina, T. Fernandez, D. Fernandez, M. Delgado, S. de Abajo, & V. Martin, 2012; L. Sarna, L. L. Danao, S. Chan, S. Shin, L. Baldago, E. Endo, & M. E. Wewers, 2006); D. Sharp, S. Blaakman, R. Cole, & J. Evinger, 2009). This paper provides an in-depth literature review of tobacco education in nursing curricula and proposes the systematic integration of theory-based tobacco content into psychiatric/mental health graduate nursing programs.

Impact of connecting tuberculosis directly observed therapy short-course with smoking cessation on health-related quality of life

Background

With evolving evidence of association between tuberculosis (TB) and tobacco smoking, recommendations for the inclusion of tobacco cessation interventions in TB care are becoming increasingly important and more widely disseminated. Connecting TB and tobacco cessation interventions has been strongly advocated as this may yield better outcomes. However, no study has documented the impact of such connection on health-related quality of life (HRQoL). The objective of this study was to document the impact of an integrated TB directly observed therapy short-course (DOTS) plus smoking cessation intervention (SCI) on HRQoL.

Methods

This was a multi-centered non-randomized controlled study involving 120 TB patients who were current smokers at the time of TB diagnosis in Malaysia. Patients were assigned to either of two groups: the usual TB-DOTS plus SCI (SCIDOTS group) or the usual TB-DOTS only (DOTS group). The effect of the novel strategy on HRQoL was measured using EQ-5D questionnaire. Two-way repeated measure ANOVA was used to examine the effects.

Results

When compared, participants who received the integrated intervention had a better HRQoL than those who received the usual TB care. The SCIDOTS group had a significantly greater increase in EQ-5D utility score than the DOTS group during 6 months follow-up (mean ± SD = 0.98 ± 0.08 vs. 0.91 ± 0.14, p = 0.006). Similarly, the mean scores for EQ-VAS showed a consistently similar trend as the EQ-5D indices, with the scores increasing over the course of TB treatment. Furthermore, for the EQ-VAS, there were significant main effects for group [F (1, 84) = 4.91, p = 0.029, η² = 0.06], time [F (2, 168) = 139.50, p = < 0.001, η² = 0.62] and group x time interaction [F (2, 168) = 13.89, p = < 0.001, η² = 0.14].

Conclusions

This study supports the evidence that an integrated TB-tobacco treatment strategy could potentially improve overall quality of life outcomes among TB patients who are smokers.

The SCIDOTS Project: evidence of benefits of an integrated tobacco cessation intervention in tuberculosis care on treatment outcomes

BACKGROUND

There is substantial evidence to support the association between tuberculosis (TB) and tobacco smoking and that the smoking-related immunological abnormalities in TB are reversible within six weeks of cessation. Therefore, connecting TB and tobacco cessation interventions may produce significant benefits and positively impact TB treatment outcomes. However, no study has extensively documented the evidence of benefits of such integration. SCIDOTS Project is a study from the context of a developing nation aimed to determine this.

METHODS

An integrated TB-tobacco intervention was provided by trained TB directly observed therapy short-course (DOTS) providers at five chest clinics in Malaysia. The study was a prospective non-randomized controlled intervention using quasi-experimental design. Using Transtheoretical Model approach, 120 eligible participants who were current smokers at the time of TB diagnosis were assigned to either of two treatment groups: conventional TB DOTS plus smoking cessation intervention (integrated intervention or SCIDOTS group) or conventional TB DOTS alone (comparison or DOTS group). At baseline, newly diagnosed TB patients considering quitting smoking within the next 30 days were placed in the integrated intervention group, while those who were contemplating quitting were assigned to the comparison group. Eleven sessions of individualized cognitive behavioral therapy with or without nicotine replacement therapy were provided to each participant in the integrated intervention group. The impacts of the novel approach on biochemically validated smoking cessation and TB treatment outcomes were measured periodically as appropriate.

RESULTS

A linear effect on both 7-day point prevalence abstinence and continuous abstinence was observed over time in the intervention group. At the end of 6 months, patients who received the integrated intervention had significantly higher rate of success in quitting smoking when compared with those who received the conventional TB treatment alone (77.5% vs. 8.7%; p < 0.001). Furthermore, at the end of TB treatment (6 months or later), there were significantly higher rates of treatment default (15.2% vs. 2.5%; p = 0.019) and treatment failure (6.5% vs. 0%; p = 0.019) in the DOTS group than in the SCIDOTS group.

CONCLUSION

This study provides evidence that connecting TB-tobacco treatment strategy is significant among TB patients who are smokers. The findings suggest that the integrated approach may be beneficial and confer advantages on short-term outcomes and possibly on future lung health of TB patients who quit smoking. This study may have important implications on health policy and clinical practice related to TB management among tobacco users.