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

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.

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.