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

From: Scaling up tobacco cessation within TB programmes: findings from a multi-country, mixed-methods implementation study

ExpandNet nine steps to scale-up TB & Tobacco Consortium actions in relation to ExpandNet’s “CORRECT”a intervention attributes to enable scale-up and principles of enhanced scalability, systems thinking, sustainability, equity Lessons learned and reflections of TB & Tobacco Consortium actions
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)
  1. aExpandNet’s “CORRECT”: C = credible; O = observable; R = relevant; Ra = relative advantage; E = easy to use; Co = compatible; T = testable (WHO 2020 p. 17 [20])