Measuring fidelity to delivery of a new smoking cessation intervention integrated into routine tuberculosis care in Pakistan and Bangladesh: Contextual differences and opportunities

Melanie Boeckmann; Omara Dogar; Saima Saeed; Arman Majidulla; Shilpi Swami; Amina Khan; Kamran Siddiqi; Daniel Kotz

doi:10.18332/tid/133054

Measuring fidelity to delivery of a new smoking cessation intervention integrated into routine tuberculosis care in Pakistan and Bangladesh: Contextual differences and opportunities

Tob Induc Dis. 2021 Apr 8:19:24. doi: 10.18332/tid/133054. eCollection 2021.

Authors

Melanie Boeckmann^{1

2

3}, Omara Dogar^{2

4}, Saima Saeed⁵, Arman Majidulla⁵, Shilpi Swami^{6

2}, Amina Khan⁷, Kamran Siddiqi^{2

8}, Daniel Kotz^{3

4}

Affiliations

¹ School of Public Health, Bielefeld University, Bielefeld, Germany.
² Department of Health Sciences, University of York, York, United Kingdom.
³ Addiction Research and Clinical Epidemiology Unit, Institute of General Practice, Medical Faculty of the Heinrich-Heine-University, Düsseldorf, Germany.
⁴ Usher Institute, University of Edinburgh, Edinburgh, United Kingdom.
⁵ Indus Hospital, Karachi City, Pakistan.
⁶ Evidera, London, United Kingdom.
⁷ The Initiative, Islamabad, Pakistan.
⁸ Hull York Medical School, University of York, York, United Kingdom.

Abstract

Introduction: Tobacco smoking among tuberculosis (TB) patients leads to poorer treatment outcomes. Smoking cessation support should be integrated into routine TB care. We measured healthcare providers' fidelity to a smoking cessation intervention integrated into routine TB care, in Bangladesh and Pakistan. We aimed to understand the role of providers and settings in the implementation of behavior support (BS) messages for TB and smoking cessation.

Methods: The integrated BS intervention was implemented in TB clinics (24 public and 1 private). Cross-sectional data were collected on the fidelity of delivery of the BS intervention using a predefined fidelity index based on an existing validated method of measuring intervention fidelity. Audio-recordings of patient-provider BS sessions were coded using the fidelity index. Intervention fidelity was presented as the proportion of sessions that implemented BS messages.

Results: A total of 96 sessions were conducted, 37 in Bangladesh and 59 in Pakistan. In public settings, TB medication advice was offered in 91.9% (95% CI: 78.7- 97.2) of sessions in Bangladesh, and in 75.5% (95% CI: 62.4-85.1) of sessions in Pakistan; whilst it was offered in 83.3% (95% CI: 43.7-97.0) of sessions in the private setting in Pakistan. Patients' smoking status was assessed in 70.3% (95% CI: 54.2-82.5) of sessions in Bangladesh, and in 34.0% (95% CI: 22.7-47.4) of sessions in the public setting and in 66.7% (95% CI: 30.0-90.3) of sessions in the private setting in Pakistan. A quit date was set in 32.4% (95% CI: 19.6-48.5) of all sessions in Bangladesh, and in 33.3% (95% CI: 9.6-70.0) of all sessions in the public setting in Pakistan.

Conclusions: Fidelity to the intended delivery of the intervention was found to be high for TB-related messages but not for smoking cessation messages. Clinic contexts may play a mediating role in health workers' opportunities to deliver the intervention as planned.

Trial registration: International Standard Randomized Clinical Trial Number (ISRCTN43811467). Registered 23 March 2016, https://doi.org/10.1186/ISRCTN43811467.

Keywords: South Asia; behavior change; primary health care; tobacco.