Improving TB outcomes by modifying life-style behaviours through a brief motivational intervention (PROLIFE)

Lead Research Organisation: Sefako Makgatho Health Sciences Universi

Abstract

TB is caused by a bacterium that spreads from person-to-person. However, compared to general population, people who smoke tobacco and drink excess amounts of alcohol are more likely to catch TB and die from it. Furthermore, they are less likely to take their TB and HIV (if co-infected) medicines, leading to treatment failure and death. Unfortunately, alcohol use and/or tobacco smoking are common among TB patients in South Africa. Therefore, addressing these major risk factors should be a key priority in TB treatment. We aim to develop and test a new approach - the PROLIFE model – to modify these behaviours in TB patients. The PROLIFE model comprises of brief one-to-one counseling sessions between TB patients and lay health workers augmented with subsequent text messaging. This will be offered in primary healthcare clinics located in three high TB burden provinces in South Africa. We will test the PROLIFE model by comparing the results of those clinics that receive it with those that don’t. We will also study which factors enable and which acts as barriers to offering the PROLIFE model. Our team consists of scientists from different disciplines and collaborators from a wide range including policy makers, managers, health professionals and advocacy forums.

Technical Summary

One in four tuberculosis (TB) deaths in South Africa could be prevented if tobacco smoking were eliminated and 10% of the global burden of TB is attributable to alcohol use. Both smoking and harmful alcohol use in TB patients have been associated with poor drug adherence and low treatment success. Furthermore, if TB patients are also co-infected with HIV, non-initiation of antiretroviral treatment (ART) or poor adherence to ART increases the risk of adverse effects and death. Alcohol and/or tobacco smoking are common among TB patients in South Africa. Moreover these lifestyle behaviours occur more often among men who are at greater risk of late care seeking for HIV. Therefore addressing these lifestyle behavioural risk factors in an integrated way could improve TB treatment outcomes. Such an intervention may also impact on the transmission of TB, as family members of smokers, children in particular, are more likely to acquire TB than those of non-smokers.
We aim to develop a complex behavioural intervention, the PROLIFE model comprised of a brief motivational interviewing (MI) counseling strategy augmented with subsequent text messaging. The MI intervention will target several areas, as appropriate: tobacco smoking, alcohol drinking and TB and ART adherence or ART initiation. The PROLIFE model - building on our earlier success of a trial of MI for smoking cessation in TB patients, will be evaluated through a pragmatic, prospective, two-arm cluster randomised control trial (cRCT) in primary health care clinics located in high TB burden communities in three provinces in South Africa. This project will be underpinned by a robust implementation science approach, which will include a longitudinal process evaluation based on the MRC’s evaluation framework for complex interventions with analysis guided by the normalization process theory. This framework will ensure that the PROLIFE model of delivery is fully cognisant of the contextual barriers and facilitators to implementation before, during and after the cRCT, in order to enable scaling up of the PROLIFE model to other areas of South Africa, as well as the translation of the model to other Sub-Saharan African countries. It will also ensure the buy-in and involvement of clinicians, lay health workers, patients, health service managers and policy makers, and that the value of the model from multiple perspectives is taken into account. PROLIFE involves an international, multidisciplinary team, including researchers in TB, public health and policy, implementation science, addiction research, health services research, primary care, health economics, mHealth, and government.

Publications

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Title Context-adapted Motivational Interviewing based training package and SMS-package for patients with tuberculosis 
Description A complex behavioural intervention package to reduce risky drinking, promote smoking cessation and promote treatment adherence in patients undergoing TB treatment is a priority for improving TB outcomes. However, there are only limited materials developed on how to deliver such an intervention. Our team has therefore developed a motivational interviewing package complemented with an SMS-package with training materials suitable for the training of by lay health workers with limited professional education. This therefore remains an important research tool going forward. 
Type Of Material Improvements to research infrastructure 
Provided To Others? No  
Impact We are currently pilot testing this package at 3 clinics in 3 provinces on a minimum of 3 patients per lay counsellor. The results are not yet known. 
 
Description Research partnership 
Organisation Medical Research Council of South Africa (MRC)
Country South Africa 
Sector Public 
PI Contribution Provides expertise for Motivational interviewing and qualitative research techniques
Collaborator Contribution Partners provided capacity for training lay counsellors and monitoring tool for their effectiveness in practice
Impact Motivational Interviewing Training Manual and SMS package
Start Year 2016
 
Description Research partnership 
Organisation Sefako Makgatho Health Sciences University
Country South Africa 
Sector Academic/University 
PI Contribution Provides expertise for Motivational interviewing and qualitative research techniques
Collaborator Contribution Partners provided capacity for training lay counsellors and monitoring tool for their effectiveness in practice
Impact Motivational Interviewing Training Manual and SMS package
Start Year 2016
 
Description Research partnership 
Organisation University of Cape Town
Country South Africa 
Sector Academic/University 
PI Contribution Provides expertise for Motivational interviewing and qualitative research techniques
Collaborator Contribution Partners provided capacity for training lay counsellors and monitoring tool for their effectiveness in practice
Impact Motivational Interviewing Training Manual and SMS package
Start Year 2016
 
Description Research partnership 
Organisation University of East Anglia
Country United Kingdom 
Sector Academic/University 
PI Contribution Provides expertise for Motivational interviewing and qualitative research techniques
Collaborator Contribution Partners provided capacity for training lay counsellors and monitoring tool for their effectiveness in practice
Impact Motivational Interviewing Training Manual and SMS package
Start Year 2016
 
Description Research partnership 
Organisation University of Free State, Bloemfontein
Department Centre for Health Systems Research and Development
Country South Africa 
Sector Academic/University 
PI Contribution Provides expertise for Motivational interviewing and qualitative research techniques
Collaborator Contribution Partners provided capacity for training lay counsellors and monitoring tool for their effectiveness in practice
Impact Motivational Interviewing Training Manual and SMS package
Start Year 2016
 
Description Research partnership 
Organisation University of Pretoria
Department School of Health Systems and Public Health
Country South Africa 
Sector Academic/University 
PI Contribution Provides expertise for Motivational interviewing and qualitative research techniques
Collaborator Contribution Partners provided capacity for training lay counsellors and monitoring tool for their effectiveness in practice
Impact Motivational Interviewing Training Manual and SMS package
Start Year 2016
 
Description Research partnership 
Organisation University of York
Department Department of Chemistry
Country United Kingdom 
Sector Academic/University 
PI Contribution Provides expertise for Motivational interviewing and qualitative research techniques
Collaborator Contribution Partners provided capacity for training lay counsellors and monitoring tool for their effectiveness in practice
Impact Motivational Interviewing Training Manual and SMS package
Start Year 2016
 
Description Research partnership 
Organisation University of the Witwatersrand
Country South Africa 
Sector Academic/University 
PI Contribution Provides expertise for Motivational interviewing and qualitative research techniques
Collaborator Contribution Partners provided capacity for training lay counsellors and monitoring tool for their effectiveness in practice
Impact Motivational Interviewing Training Manual and SMS package
Start Year 2016
 
Title Motivational Interviewing for Lifestyle Behaviour Modification in Tuberculosis Patients 
Description Initial development and pilot stage complete. The PROLIFE package/ intervention is now being evaluated for effectiveness and cost-effectiveness through a randomised controlled trial. 
Type Preventative Intervention - Behavioural risk modification
Current Stage Of Development Refinement. Non-clinical
Year Development Stage Completed 2017
Development Status Under active development/distribution
Impact None yet 
 
Description European Congress on Tropical Medicine and International Health 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact This was a poster presentation to academics, policy makers, postgraduate students and other professionals attending the 10th European Congress on Tropical Medicine and International Health in October 2017 in Antwerp.
Year(s) Of Engagement Activity 2017
 
Description Oral presentation- School of Health systems & Public Health Medicine, University of Pretoria 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact This was a presentation at a seminar which sparked questions about the project and how to address lifestyle rick factors among TB patients.
Year(s) Of Engagement Activity 2017
 
Description Poster presentation- 13th Conference of the Public Health Association of South Africa 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact This was a poster presentation with an opportunity for attendees to ask questions about the PROLIFE project.
Year(s) Of Engagement Activity 2017
 
Description Society for Research on Nicotine and Tobacco 2017 Annual Meeting 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Our research team presented a poster on the work from the PROLIFE project, based on the secondary data analysis of Demographic and Health Surveys from 28 low- and middle- income countries. This work showed that the prevalence of tobacco use among people living with HIV in these countries is generally higher than that among HIV negative individuals. This increased interest on the subject. Since then, the team has built research partnerships aimed at pursuing collaborative projects on tobacco use among people living with HIV.
Year(s) Of Engagement Activity 2017
 
Description Society for Research on Nicotine and Tobacco conference 2019 (San Francisco) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact This was an invited oral presentation to disseminate the results of the PROLIFE feasibility study. There were about 20 people in attendence and the study generated interest and discussions around the best way to deliver smoking cessation interventions for people living with TB and those living with HIV.
Year(s) Of Engagement Activity 2019
 
Description The 47th Union World Conference on Lung Health 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Our research team held a symposium in collaboration with colleagues from the World Health Organization and Johns Hopkins Medical Institutions which generated discussion and debate on the following topic: 'Should addressing tobacco use in TB and HIV patients be integral to disease control programmes?'. Five presentations were included in the symposium and between 30 and 40 individuals attended. Our team orally presented work from the PROLIFE project, based on the secondary data analysis of Demographic and Health Surveys from 28 low- and middle- income countries. This work showed that the prevalence of tobacco use among people living with HIV in these countries is generally higher than that among HIV negative individuals. This increased interest on the subject. Since then, there has been a call for research grant proposals from the National Institutes of Health, USA focused on tobacco use and HIV infection in low and middle income countries (funding opportunity PAR-17-087).
Year(s) Of Engagement Activity 2016