Addressing tobacco smoking and drinking to improve TB treatment outcomes, in South Africa: a feasibility study of the ProLife program

Abstract

Alcohol and tobacco use may lead to negative treatment outcomes in tuberculosis (TB) patients, and even more so if they are HIV-infected. We developed and tested the feasibility of a complex behavioral intervention (ProLife) delivered by lay health workers (LHWs) to improve treatment outcomes in TB patients who smoke tobacco and/or drink alcohol, at nine clinics in South Africa. The intervention comprised three brief motivational interviewing (MI) sessions augmented with a short message service (SMS) program, targeting as appropriate: tobacco smoking, harmful or hazardous drinking and medication adherence. Patients received SMSs twice a week. We measured recruitment and retention rates and assessed fidelity to the MI technique (MI Treatment Integrity 4.1 tool). Finally, we explored LHWs’ and patients’ experiences through interviews and semi-structured questionnaires, respectively. We screened 137 TB patients and identified 14 smokers, 13 alcohol drinkers, and 18 patients with both behaviors. Participants’ mean age was 39.8 years, and 82.2% were men. The fidelity assessments pointed to the LHWs’ successful application of key MI skills, but failure to reach MI competency thresholds. Nevertheless, most patients rated the MI sessions as helpful, ascribed positive attributes to their counselors, and reported behavioral changes. SMSs were perceived as reinforcing but difficult language and technical delivery problems were identified as problems. The LHWs’ interview responses suggested that they (a) grasped the basic MI spirit but failed to understand specific MI techniques due to insufficient training practice; (b) perceived ProLife as having benefitted the patients (as well as themselves); (c) viewed the SMSs favorably; but (d) considered limited space and privacy at the clinics as key challenges. The ProLife program targeting multiple risk behaviors in TB patients is acceptable but LHW training protocol, and changes in wording and delivery of SMS are necessary to improve the intervention. Trial registration: ISRCTN14213432

A narrative review of facilitators and barriers to smoking cessation and tobacco-dependence treatment in patients with tuberculosis in low- and middle-income countries

“…*** *** Living in urban areas, office jobs, being single significantly increased the intention to quit smoking 22 Combined interventions 13,19,20 Brief, but repeated interventions, motivation, brochures [15][16][17]28,31 Tobacco-free healthcare facilities 25 Time from waking to first cigarette of >30 min, routine screening for smoking, having a smoke-free home and display of 'no smoking' sign at home, regular reminders and encouragement of by family members to quit smoking 25 Willingness to quit -higher in those with previous attempt(s) in the past year 32 Incorporating of training in brief advice into existing training of DOTS providers 33 Personalized behavioural counselling incorporated into routine TB services 24,35,43,46 High level of awareness regarding smoking risk for health 36 Multiple risk behaviour interventions 37 Repeated tobacco use intervention follow-up at a minimum of 6 months after end of TB treatment 30,43 Providing intervention not only at a health facility but also on a daily basis at community level by health volunteers 46…”

“…Limited space and privacy at the clinics 37 Male gender, lower education 38 Daily smoking of more than 15 cigarettes/bidis at the time of diagnosis 41 Patients' cards without the provision to include about brief advice on smoking cessation given which has been mentioned in the TB treatment guidelines; lack of coordination between the TB treatment programme and tobacco cessation 39,43 Identified in patients with drug-resistant TB:…”

Brief psychotherapy administered by non-specialised health workers to address risky substance use in inpatients with multi-drug resistant tuberculosis: A feasibility and acceptability study

“…17.5 (15-24) versus 6 (6-8), Z = 6.206, p < 0.0001). Depressive symptomatology improved, with the median (IQR) CES-D score significantly lower post-intervention [23.5 (18-34) vs. 17 (13)(14)(15)(16)(17)(18)(19)(20)(21)(22), p < 0.01].…”

“…These interventions are typically based on cognitive-behavioural and motivational interviewing techniques. A number of studies have been conducted in South Africa investigating the effectiveness of SBI among patients presenting to emergency centres (15), women receiving antenatal care (16), people receiving treatment for human immunodeficiency virus (HIV) and other chronic diseases in primary care settings (17)(18)(19), and hospitalised inpatients at a district-level hospital (20) and TB patients (12,13).…”

Brief psychotherapy administered by non-specialised health workers to address risky substance use in inpatients with multi-drug resistant tuberculosis: A feasibility and acceptability study

“…Evidence-based strategies for addressing problem substance use among patients with TB may include methadone treatment for hospitalised opioid dependence (10), smoking cessation interventions through programmatic care (11), and screening and brief interventions to address hazardous and harmful alcohol use (12). Few intervention studies have addressed substance use within the context of TB in South Africa: those that have been conducted are limited to alcohol and tobacco among patients with drug-susceptible TB who are being treated in outpatient settings (13). Given the limited literature, further work is needed, particularly in low and middle-income countries, where there are limited specialized mental health clinicians.…”