Improving treatment for TB patients

Five early lessons from the alcohol and smoking behavior interventions with TB care study.

Tobacco and alcohol use has been found to negatively affect the success of TB treatment.

In November 2018, UNDP Zimbabwe partnered with Ministry of Health and Child Care, and the Biomedical Research and Training Institute to further understand this relationship between tobacco and alcohol intake and TB treatment outcomes.

Half way through the study, the intervention draws interesting early lessons — a potential for future replication and scale-up.

1. Clinicians are key

The successful treatment of TB patients who smoke tobacco and drink alcohol is likely determined by the clinicians who identify them and walk the treatment journey with them.

Many factors determine the number of patients recruited into the study in an area. However, it seems the health professional’s passion and motivation plays a significant role in identifying them, and ultimately helping them reduce or stop drinking and smoking while on treatment.

This is evidenced by the study not taking off at one of the health facilities where a non-TB clinician had been selected to train and participate in the study.

2. Relationships key to commitment and recovery

An unmeasured parameter of the study is the relationship formed between the clinician and the patient during treatment. In five of the six locations visited, patients mentioned how their relationship with their clinician was the main reason they stopped or reduced smoking and drinking.

“I owe my recovery to Mr. Sithole”, 47 year old Silas* says of the TB focal point at Birchenough Bridge Hospital. “Every time I came here to pick up medication, our conversations would encourage me stick to my commitment to stop drinking.” Silas used to be a heavy drinker before his TB diagnosis.

“Sister Brenda** is like my own real sister. We don’t just talk about my treatment. I feel comfortable telling her about my social life, and I look forward to the advice she gives me about my family’s health” — Chipo*, Masvingo General Hospital

Chipo, 33 year old mother of two, compares this relationship to her previous clinician who had just abruptly broke her diagnosis to her without preparing her.

27 year old Nkosinathi* says “I am free to tell her everything because she treats me like her own brother...I thought if she cares this much for my recovery, then her advice for me to stop must be good for me.”

3. Tools for treatment

As part of the study design, participating patients were given a T-Shirt and wristbands at different stages of treatment to applaud their commitment to reduce or stop smoking and drinking. For some patients, the tools proved to be a useful as they associated them with their treatment progress.

“I have been smoking all my adult life so sudden withdrawal was very difficult for me, especially in the mornings. A couple of times I would give in and light a cigarette. But as I lifted it up to my mouth, I saw the wristband and remembered the commitment I had made to myself for my recovery” — Brian*, Gweru General Hospital

Another patient in Kadoma, who had just completed his TB treatment and had completely recovered, says he always wore his “Stop Drinking and Smoking” T-Shirt when going out to meet his friends at the local pub. “When they offer me a beer, I just point to my T-Shirt and continue sipping on my water or juice” he laughs.

4. Innovative engagement approaches

“Almost all patients will initially say I do not drink or smoke anymore. But you need to continue probing and changing the way you ask questions until they disclose” — Mr Jacob Mulanzi**, Kadoma General Hospital

At all the health facilities that are active in the study visited, the clinicians have devised unique approaches to identifying those who smoke and drink.

In Gweru and Kadoma, TB prevalence is relatively high because of unprotected artisanal mining activities in the region. In addition, patients are heavily influenced by their peers and environment at the mines to smoke and drink despite on-going TB treatment. Sister Jacob Mulanzi has discovered that his patients are more likely to adhere to treatment and commitment with family support. So he encourages patients to bring their spouses or families for treatment. This helps to counter the negative environment and behaviors at the mines. “Spouses tend to be more truthful during the initial probe. We also give them more information to help with psychological and dietary support,” he says.

Sister Stella Manyere, the TB focal point at Rimuka Hospital in Kadoma has formed formidable partnership with her colleague and drug dispenser, Mr. Marandu, who is well known in the area.

Most of their patients feel the duo has created a safe environment to be truthful and disclose their challenges.

“I don’t ask about their smoking or drinking habits on the first day of treatment. Most do not know me enough to trust me. But on the second or third visit when they are confident that I am dedicated to their recovery, I bring out my questionnaire. Some of them even begin to tell me before I ask.” — Sister Kumbirai Matende, Gweru General Hospital

5. Peers and past patients as champions

“My friend seems to be facing the same challenges I faced. Because of my experience, I keep advising him to stop drinking and smoking and to go and get checked for TB.” — Stanley*, Birchenough Bridge

There is scope to work with current and past patients to reach out to their colleagues, both undiagnosed and on-treatment, to stop smoking and drinking. Because of their experiences, they are better placed to communicate successfully to their peers. In addition, they are likely to meet more people who, like them, drink or smoke and are more exposed to TB because of their environment.

Tuberculosis (TB) remains one of the deadliest infectious diseases worldwide. The proliferation and deadliness of the disease are closely associated with tobacco and alcohol consumption, with smokers being twice as likely to develop active TB and those who drink more than 40 grams of alcohol per day, three times more likely.

The project is working to develop behaviourally informed strategies to reduce alcohol and cigarette use, using low-cost strategies to identify interventions that increase adherence to TB treatment.

  • * Not their real names
  • ** Nurses in Zimbabwe’s hospitals are commonly referred with the title ‘Sister’