Table 5 Mapping TB & Tobacco Consortium actions to ExpandNet scale-up steps and framework

Step 1: Planning actions to increase the scalability of the innovation

Adaptation of cessation intervention found effect through research in South Asia (O, C)

Engagement with national, provincial, regional TB programmes to adapt intervention and throughout the project (R)

Reduced intervention content for shorter 10-minute cessation consultations (Co)

Adding one-page desk guide for easy reference (E)

Policy and guideline review (R)

RCT evidence from Pakistan and Bangladesh (7) of the effectiveness of the 10-minute cessation consultation enhanced the credibility of the intervention for policy-makers and practitioners, particularly as evidence showed the relative advantage over pharmaceutical interventions or no quit support (6, 48)

Facilitating TB health workers to adapt and apply the intervention to their context helped with relevance, ownership and compatibility

Policy review highlighted limited attention to tobacco cessation in existing policies and plans, indicating that although there is no comprehensive tobacco cessation programme in Bangladesh, Pakistan or Nepal, concern that felt need/relevance may not be great

Step 2: Building the capacity of the user organization for scale-up

Training trainers in the TB health system (Co)

Working with NTPs to identify NTP staff to train as trainers (R)

Designing short training sessions for use in routine TB programme (Co) with videos to maintain quality and consistency (C)

Assessing capacity, opportunity and motivation of TB health professionals (T)

Developing and filming videos provided an opportunity for further engagement of NTP staff and TB health workers at all levels increased buy-in of TB programmes; e.g., Nepal’s NTP director introduced the training video

Filming in TB clinics and modelling real-life consultations enhanced relevance

Challenging to identify trainers likely to subsequently train others; e.g. in Nepal, eight trainers trained, but only two delivered training to TB health workers

Step 3: Assessing the environment and planning actions to increase the potential for scaling-up success

Identifying health system levers for vertical and horizontal scale-up (Co)

Engagement with NTPs at national (Bangladesh), national and provincial (Pakistan) and municipalities (Nepal) to identify learning sites (R, O, T)

Redesign of NTP recording and reporting forms (Co, T)

Redesign of NTP supervision forms (Co)

Supporting and assessing the delivery of training of health workers and dissemination of materials (Co, T)

Implementation research (IR) studies (14–16), workshops with TB managers, health workers, supervisors and research team’s in-depth knowledge of TB programmes in all three countries vital to identify health system levers

Adapting existing reporting forms and guidelines and training programmes rather than developing parallel systems enhanced compatibility but was challenging to implement

Despite increases in COM-B questionnaire scores following the short training, demand for longer training and regular refreshers highlighted that training is also seen as an incentive

In general, NTP supervision in all three countries focused on checking reporting forms rather than support to provide quality care. Greater early engagement of first-line supervisors (e.g. programme officers in Bangladesh) in the future could help address this

Step 4: Increasing the capacity of the resource team to support scaling up

In-country research teams build relationships with NTPs (R, Co)

Extended periods of research through multiple studies with national TB programmes (O, R, Co)

Co-I and TB focal point as “insider-researchers” in Pakistan (C, R, Co)

Senior members of the research team have long-standing relationships with NTP at policy and programme levels and mutual respect developed through engagement in multiple studies

More junior researchers had to build working relationships; this was particularly challenging for early-career female researchers in male-dominated hierarchies

Building these relationships was further challenged by the frequent transfer of senior NTP officials, e.g. six different NTP Line Directors in Bangladesh over the study period

Challenging for researchers to stay within their research role and not influence implementation

Step 5: Making strategic choices to support vertical scale-up (institutionalization)

Focusing on health system levers most amenable to change (Ra, Co)

Identification of a mix of rural, urban, public, private, large and small learning sites (O, R, Co)

Workshops and presentations at key events (C, Co)

Insights of “insider researchers” were valuable in ensuring compatibility and relevance of scale-up strategies

In Bangladesh and Nepal, learning sites were agreed upon with NTP at national (Bangladesh) and municipal level (Nepal), but more limited ownership of implementation by NTPs

Detailed knowledge of NTPs by the research team was key in identifying the most strategic events to engage and seizing opportunities to engage and influence in e.g. Chest Society conference and inter-provincial and inter-district meetings in Pakistan; NTP Technical Working Group and WHO events in Nepal; coordination workshops/meetings with National Tobacco Control Cell, and Noncommunicable Disease Control Programme, Ministry of Health and Family Welfare in Bangladesh

Rapid recognition of the need to engage at municipal level within the new federal context of Nepal to identify learning sites and train, as trainers supported ownership and integration of the intervention at the municipal level

Step 6: Making strategic choices to support horizontal scale-up (increased coverage)

Sharing findings, including costs, from learning sites via policy briefs and workshops (O, Ra, T)

Way Forward workshops with NTP, donor and NGO stakeholders in all three countries to build on findings to plan scale-up beyond learning sites (C, O, R)

Feeding into TB strategic planning processes (R)

Engaging global policy-makers (WHO, United Nations Development Programme, Tobacco Control) and International Union against TB and Lung Disease (C, R)

Inclusion of private sector and NGO providers to enhance testability (T) within different contexts vital within the pluralistic health system

Collection of cost data valued by decision-makers within NTPs

Multiple channels are needed for dissemination e.g. “Way Forward” workshops, policy briefs and availability of all materials in Urdu, Bengali and Nepali

Dissemination most effective when linked to forward planning

Integration of tobacco cessation within TB programmes gaining global traction, but TB & Tobacco advisors working in silos. Growing recognition of the need for tobacco indicators within Global Fund proposals and monitoring

Engagement of senior researchers in the team in health sector planning (e.g. in Bangladesh: annual programme review (APR) and midterm review (MTR) of the 4th Health Sector Programme of Bangladesh, road map to make Bangladesh tobacco-free by 2040). In Pakistan, engagement in processes to develop the 2020–2023 strategic plan, which highlighted the success in learning sites and emphasized tobacco cessation. In Nepal, engagement in the development of the NTP’s National Strategic Plan, and the funding proposal to GFATM helped to advocate and incorporate research findings to support horizontal scale-up

In Nepal, embedding research within a government in transition to federalization was challenging, but building alliances within and beyond NTP provided opportunities for horizontal scale-up

Step 7: Determining the role of diversification

Emphasizing core elements of the interventions within the health worker guide which accompanies the intervention materials (E, Co)

Encouraging adaptation to context (Co)

Tension between staying focused on delivery of the existing intervention and requests from learning sites to extend the work, e.g. to include community education campaigns on tobacco, to use within multidrug-resistant (MDR) TB programmes, greater emphasis on smokeless tobacco

Adaptation (e.g. group sessions in Pakistan’s busy clinics) and personalization of the delivery of the intervention helped ownership and adoption of the intervention

Step 8: Planning actions to address spontaneous scale-up

Videos and materials freely available online to encourage spontaneous scale-up (E, Co)

Link to online materials in all printed intervention materials (E, Co)

All materials in multiple languages (Urdu, Bengali, Nepali and English) (E, Co)

Organizations may take the initiative but only implement part of the intervention; e.g., Noncommunicable Disease Control (NCDC) Programme of Bangladesh endorsed the leaflet and printed and distributed nationally (from their own budget)

Materials adapted for use in large private TB providers in Pakistan

In Nepal, some intervention materials (i.e. posters and leaflets) were considered as NTP resources and so supplied to health facilities through NTP

Step 9: Finalizing scaling-up strategy and identifying next steps

Way Forward workshops with national TB programme policy-makers designed to identify next steps (C, R, Co)

Challenges agreeing on next steps within federal context of Pakistan, and within context of structural reorganizations in newly federal Nepal

Importance of close engagement within national NTP strategy processes e.g. greater coordination with NGOs (e.g. Bangladesh Rehabilitation Assistance Committee [BRAC]) and development partners (e.g. Global Fund) in Bangladesh

More work at global level needed to shape indicators (e.g. Global Fund)