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

Abstract

Background Tobacco use is associated with exacerbation of tuberculosis (TB) and poor TB treatment outcomes. Integrating tobacco use cessation within TB treatment could improve healing among TB patients. The aim was to explore perceptions of health workers on where and how to integrate tobacco use cessation services into TB treatment programs in Uganda. Methods Between March and April 2019, nine focus group discussions (FGDs) and eight key informant interviews were conducted among health workers attending to patients with tuberculosis on a routine basis in nine facilities from the central, eastern, northern and western parts of Uganda. These facilities were high volume health centres, general hospitals and referral hospitals. The FGD sessions and interviews were tape recorded, transcribed verbatim and analysed using content analysis and the Chronic Care Model as a framework. Results Respondents highlighted that just like TB prevention starts in the community and TB treatment goes beyond health facility stay, integration of tobacco cessation should be started when people are still healthy and extended to those who have been healed as they go back to communities. There was need to coordinate with different organizations like peers, the media and TB treatment supporters. TB patients needed regular follow up and self-management support for both TB and tobacco cessation. Patients needed to be empowered to know their condition and their caretakers needed to be involved. Effective referral between primary health facilities and specialist facilities was needed. Clinical information systems should identify relevant people for proactive care and follow up. In order to achieve effective integration, the health system needed to be strengthened especially health worker training and provision of more space in some of the facilities. Conclusions Tobacco cessation activities should be provided in a continuum starting in the community before the TB patients get to hospital, during the patients’ interface with hospital treatment and be given in the community after TB patients have been discharged. This requires collaboration between those who carry out health education in communities, the TB treatment supporters and the health workers who treat patients in health facilities.

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“…In clinical environments, activities aimed at identifying current and past smoking, routine counseling of patients seen at the clinic, offering intensive support with counseling of tobacco users, and administration of nicotine-replacement therapy for some patients. In non-clinical environments, they include educating the population about the dangers of tobacco use and passive smoking [33].…”

Cigarette Smoking as a Risk Factor for Tuberculosis in Adults: Epidemiology and Aspects of Disease Pathogenesis

“…Healthcare workers also report structural characteristics that are primary barriers to offering behavioural support for smoking cessation, including high workloads and limited time spent with each patient, among other factors such as sociocultural barriers like gender relations, stigma, or social influences, which also need to be addressed [ 50 ]. Studies among healthcare workers have also led to the recognition that tobacco smoking cessation strategies should take place in communities as well as in healthcare facilities, supported by partnerships with media and families, while also addressing healthcare challenges to support effective implementation [ 51 ]. One follow-up study, undertaken 5 years after a smoking cessation intervention in Chinese TB patients, noted that non-smokers, ex-smokers, and current smokers who received the intervention maintained higher non-smoking rates than patients who did not [ 52 ].…”