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

Abstract

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

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

“…Several barriers were connected to the healthcare system itself: limited space and privacy at the clinics 37 , lack of coordination between the TB treatment programme and tobacco cessation 39 , 43 , lack of resources (human, financial), low level of education of health providers on smoking cessation 21 , tolerance of smoking or snuff dipping at a health centre by medical assistants providing SCI, and smoking staff 30 .…”

“…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:…”

“…Socio-cultural influences (i.e. family/friends smokers) 26 Brief advice focused only on smoking could lead to a higher rate of SLT relapse seen as a form of harm reduction 29 Receiving a disease-specific cessation message -associated with a lower likelihood of smoking relapse 40 Perception of low-moderate level smoking as harmless 41 Period of follow-up: increase in relapses within the 6 months of treatment and within the 3-6 months following treatment [40][41][42] Several barriers were connected to the healthcare system itself: limited space and privacy at the clinics 37 , lack of coordination between the TB treatment programme and tobacco cessation 39,43 , lack of resources (human, financial), low level of education of health providers on smoking cessation 21 , tolerance of smoking or snuff dipping at a health centre by medical assistants providing SCI, and smoking staff 30 .…”

Health workers’ perceptions on where and how to integrate tobacco use cessation services into tuberculosis treatment; a qualitative exploratory study in Uganda

“…For those who develop complications, there should be an opportunity for referral. A study in India highlighted inadequate referral to tobacco use cessation specialized centres [ 38 ]. The importance of documentation has been stressed.…”

Health Workers’ Perceptions on Where and How to Integrate Tobacco use Cessation Services into Tuberculosis Treatment; A Qualitative Exploratory Study in Uganda

“…For those who develop complications, there should be an opportunity for referral. A study in India highlighted inadequate referral to tobacco use cessation specialized centres [37]. Referral within health service delivery is a critical factor in providing continuity in provision of services.…”