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Using a theory-informed approach to guide the initial development of a post-tuberculosis care package in British Columbia, Canada

BMC Health Services Research volume 23, Article number: 805 (2023) Cite this article

Abstract

Background

The importance of addressing the long-term needs of tuberculosis (TB) survivors is gaining increasing attention. One promising approach to improving post-TB care is implementing a post-TB care package. With a specific focus on the perspectives of healthcare providers in British Columbia, Canada, this study aimed to (1) determine a set of components to be included in a post-TB care package, (2) explore barriers and facilitators influencing their implementation, and (3) propose potential solutions to overcome identified challenges.

Methods

Employing a multi-method approach guided by the Theoretical Domains Framework, we first conducted virtual workshops with TB care providers and utilized a modified Delphi process to establish a preliminary list of care package components. Then, we surveyed healthcare providers using closed-ended, Likert-scale questions to identify implementation barriers and enablers. Lastly, we mapped the identified barriers and enablers to establish behaviour change techniques to identify possible solutions to overcome the challenges identified.

Results

Eleven participants attended virtual workshops, and 23 of 51 (45.1%) healthcare providers completed questionnaires. Identified components of the post-TB care package included:

1. Linking people with TB to a primary care provider if they do not have one.

2. Referring people with pulmonary TB for an end-of-treatment chest x-ray and pulmonary function testing.

3. Referring people with TB who smoke to a smoking cessation specialist.

4. Sharing a one-page post-TB information sheet with the patient's primary care provider, including a summary of post-TB health concerns, complications, and recommendations to prioritize age-appropriate screening for cardiovascular disease, lung cancer, and depression.

Survey results indicated that domain scores for ‘environment, context, and resources’ were the lowest, suggesting potential implementation barriers. Care navigation services to help individuals overcome health system barriers while transitioning from TB care, information leaflets, and checklists summarizing key post-TB health concerns for patients and healthcare providers to help facilitate discussions may help overcome the identified barriers.

Conclusion

Healthcare providers in British Columbia acknowledge that post-TB care is integral to comprehensive health care but are limited by time and resources. Care navigation services, a post-TB checklist, and patient information leaflets may help resolve some of these barriers.

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Contributions to the literature

  • We used a theory-informed approach to guide the initial development of a post-tuberculosis care package in British Columbia, Canada

  • Our findings highlight that healthcare providers in British Columbia believe post-tuberculosis care should consist of a few measures targeting key health concerns, but its implementation may be limited by time and resources.

  • The methodology and findings from our study may serve as an example for other tuberculosis programs to generate actionable information to help guide the design and implementation of post-tuberculosis services.

Background

Approximately 10 million people worldwide develop active tuberculosis (TB) every year, and about 85% of people diagnosed are successfully treated [1]. While successful treatment is often seen as a return to pre-TB health, accumulating evidence highlights that many people who survive TB face elevated mortality risk and ongoing health challenges, including pulmonary impairment, cardiovascular disease, depression, and reduced health-related quality of life [2,3,4,5,6]. Despite the recognition of these long-term needs, TB programs have traditionally focused on timely diagnosis, treatment adherence and prevention, with limited attention given to post-TB care.

Nevertheless, the importance of addressing the long-term needs of TB survivors is gaining increasing attention [7]. Although limited evidence exists to identify effective interventions addressing the health challenges faced by TB survivors [8], newly published international standards and guidelines, including the 2022 Canadian TB Standards, emphasize the importance of assessing and managing post-TB complications [9, 10]. Recommendations include assessment for post-TB lung disease, pulmonary function testing for people with pulmonary TB, and addressing comorbidities during TB treatment in partnership with primary care providers [10]. However, the optimal strategies for implementing these recommendations remain unclear.

Implementing care packages is a promising approach to improving post-TB care and addressing comorbidities. Care packages typically comprise of three to five evidence-informed interventions or practices performed collectively and reliably [11]. Often, they are considered complex interventions due to their multifaceted nature and the need for behaviour change among those responsible for their implementation; thus, using a theoretical approach when developing care packages can enhance the understanding of healthcare providers’ behaviours and facilitate successful design and implementation [12].

The Theoretical Domains Framework (TDF) is a widely used theoretical framework that encompasses 14 domains of behaviour change [13, 14]. It was developed using an expert consensus process and validation to identify psychological and organizational theories relevant to health practitioner clinical behaviour change [13, 14]. The process of using the TDF for intervention design has been outlined in detail and applied extensively [13, 15,16,17].

In this study, we employed a multi-method approach, utilizing the TDF to guide the initial development of a post-TB care package in British Columbia, Canada. With a specific focus on the perspectives of healthcare providers, we aimed to (1) determine the components to be included in a post-TB care package, (2) explore barriers and facilitators influencing their implementation, and (3) propose potential solutions to overcome identified challenges.

Methods

Study setting

This research was conducted in British Columbia, Canada, a province with 4.9 million people and an active TB incidence of 6.0 per 100 000 population [18], in conjunction with Provincial TB Services at the British Columbia Centre for Disease Control (BCCDC). The BCCDCProvincial TB Services is a centralized health agency responsible for diagnosing and treating most people with active and latent TB throughout British Columbia; they also consult with healthcare providers and coordinate case management for drug-resistant and complex pediatric TB. Embedded within TB services are two provincial TB clinics located in Greater Vancouver.

Ethical approval of the study was provided by the University of British Columbia Behavioural Research Ethics Board (Behavioural Research Ethics Board Certificate #H22-00732). We report this study following the Guidance for Reporting Intervention Development Studies in Health Research (GUIDED) checklist (Supplementary Appendix) [19].

Study design

For this study, we followed the steps outlined by French et al. on developing theory-informed interventions using the TDF. [13] Briefly, these steps include (1) determining the target behaviours, (2) exploring what enablers and facilitators need to be addressed for successful implementation, (3) identifying possible solutions to overcome the barriers and facilitators, and (4) synthesizing the evidence to design the intervention package. For each step, we worked collaboratively with healthcare providers and relevant stakeholders [20]. The process we used is illustrated in Fig. 1, and each step is described below.

Fig. 1
figure 1

Overview of the development process

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Step 1: Post-TB care workshops

First, we held a series of virtual workshops with healthcare providers specializing in TB care at the BCCDC-TB clinics and general practitioners in British Columbia to determine a preliminary list of components to be included in a post-TB care package. Using convenience sampling from urban and rural areas, we recruited TB healthcare providers and general practitioners. At these workshops, we presented participants with an overview of the evidence from a scoping review on existing interventions to reduce post-TB morbidity [21] and national and international standards on post-TB care [9, 10]. During these workshops, we discussed post-TB care and potential post-TB care package components (Supplemental Table 1), focusing on their applicability in TB clinics in British Columbia.

We then used a modified Delphi consensus method to identify which components should be considered key components of post-TB care package in British Columbia [22]. We used an anonymous online voting platform to reach a consensus on a preliminary list of components to be included in a post-TB care package. All participants had the opportunity to add any other potential components they believed were missing before voting began.

The online voting platform included a disclaimer which stood in place of a signed formal consent form. Participants needed to agree to the disclaimer before participating in the voting. Each potential post-TB care package component was presented and then rated as “agree,” “disagree,” or “neither agree nor disagree.” When consensus on a component was reached, we summarized it in behavioural terms, including target behaviour, the content to be delivered, to whom, by what mode, and how often [23].

Step 2: Survey healthcare providers

Survey healthcare providers

Once we determined a preliminary list of components to include in a post-TB care package, we surveyed healthcare providers working within the BCCDC-TB clinics to identify any barriers and enablers to their successful implementation.

Questionnaire development

We developed an anonymous, self-administered, web-based questionnaire for assessing the domains of behaviour change. The questionnaire was adapted from a generic English questionnaire provided by Huijg et al. (2014), which was developed to discriminately assess the majority of TDF domains and can be tailored to suit different contexts [24].

The final version of the questionnaire consisted of 22 items (two to five items per domain). It covered eight TDF domains: knowledge, skills, professional role, beliefs about capabilities, consequences, optimism, environment, and memory. We excluded behaviour regulation, goals, and reinforcement, as prior research shows these domains lack discriminant validity [24, 25]. We also excluded the domain's social influence, intention, and emotion, as initial feedback indicated that our initial survey required tailoring to increase acceptance. A copy of the questions and the corresponding domain for each question is presented in Supplemental Table 2. The questions were randomly arranged, and respondents were asked to respond on a five-point Likert scale, from strongly agree to disagree strongly.

We also included two questions about which components of post-TB care healthcare providers believed were acceptable and which components they believed were part of their role as healthcare providers.

Participants and data collection

All healthcare providers (nursing, physician, pharmacist, and social workers) at the BCCDC-TB clinics were invited to participate via email between May and June 2022. Participants meeting the inclusion criteria were sent an invitation email, which explained the purpose of the study, estimated completion time, and a link to the survey. The survey was conducted using a web-based Qualtrics Survey Tool. The beginning of the survey had a disclaimer which stood in place of a signed formal consent form. Participants needed to agree to the disclaimer before participating in the survey. We sent a reminder email two and four weeks after the initial invitation, and the survey was championed at internal staff meetings.

Statistical analysis

Returned surveys were given a sequential identification number. We calculated internal consistency estimates for each theoretical domain using Cronbach’s alpha, with a cut-off of 0.50, as used in prior preliminary intervention design research [16, 17]. An alpha of less than 0.50 indicated variability in how healthcare providers responded to the different questions within that domain. Individual domain scores were based on responses measured on a five-point Likert scale (1 = strongly disagree, 5 = strongly agree); the scales were reversed for negatively worded questions. We calculated a mean domain score and standard deviation for each domain. The domain scores were then presented; a low mean domain score suggests the domain may be a barrier to implementation, while a high value indicates the domain may facilitate implementation. All analyses were conducted in R (V.4.0.2.) [26].

Step 3: Map barriers and enablers

Once survey results were compiled, we mapped the identified barriers and enablers to appropriate behaviour change techniques to identify implementation mechanisms. This was done using the Theory and Techniques tool [27]. The Theory and Techniques Tool is a rigorously developed matrix to help identify integration strategies to overcome barriers and leverage enablers identified in Step 2 [27,28,29]. It is based on synthesized evidence from the literature and expert consensus on individual strategies' effectiveness in eliciting behaviour change [27,28,29].

Step 4: Evidence synthesis

After synthesizing all available evidence, study team members and implementation partners, including healthcare providers and administrators within BCCDC-Provincial TB Services, virtually reviewed the evidence to refine the components and implementation mechanisms. Implementation partners were invited to participate via email and selected based on their relevant expertise. Discussion points focused on what was locally appropriate, feasible, and could be implemented as part of a cohesive approach to post-TB care in British Columbia. Discussions also encompassed potential outcome measures that could be used to evaluate the effectiveness of the care package once it has been implemented.

Results

Step 1: Post-TB health workshops

Eight participants attended our first workshop, including three TB physicians, four TB nurses, and one social worker working within the TB Clinics. Three general practitioners participated in our second workshop. Identified post-TB care package components are presented in Table 1 and include (1) linking people to a primary care provider, (2) referring people with pulmonary TB for an end-of-treatment chest x-ray and pulmonary function testing, (3) referring people who smoke to a smoking cessation specialist and (4) providing an information sheet to the patient's primary care provider on post-TB health.

Table 1 Potential post-TB care package components identified during the healthcare provider workshops (Step 1)
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Discussions during the workshop with general practitioners emphasized the need for care navigation services for individuals to help them overcome healthcare system barriers and facilitate timely access to quality healthcare while transitioning out of TB care. Additional concerns raised by general practitioners were appropriate and timely transitions to primary care and the need for increased communication between TB healthcare providers and general practitioners rather than the need to screen for multiple comorbidities in this population.

Step 2: Survey healthcare providers

A total of 23 of 51 questionnaires (45.1%) were completed and returned. The distribution of responses is presented in Supplemental Table 2, and the demographic characteristics of questionnaire participants are shown in Supplemental Table 3. Internal consistency for each theoretical domain and the mean domain score are presented in Table 2. The mean domain scores were highest for optimism, knowledge, and professional role. Conversely, beliefs about consequences, capabilities, and environment, context, resources had the lowest mean domain scores.

Table 2 Mean domain scores and Cronbach’s alpha for the healthcare provider survey (Step 2)
Full size table

We identified seven key barriers to implementing post-TB care, including healthcare providers not having enough time, handouts, or referral options to discuss post-TB health concerns; them not feeling confident providing post-TB care; and being more concerned about other TB issues than post-TB health concerns. Facilitators included respondents believing it is their responsibility as care providers to discuss post-TB health concerns as part of routine care, and that incorporating post-TB care as routine care would help improve the long-term health of this population (Table 3).

Table 3 Identified barriers mapped to the theoretical domains and corresponding behaviour change techniques (Step 3)
Full size table

Our results also indicated that over 70% of respondents supported linking patients to primary healthcare providers, referring those who smoke to a smoking cessation specialist, and assessing for post-TB lung disease. However, only approximately 60% of respondents believed that it was part of their role as healthcare providers to perform these actions (Supplemental Fig. 1).

Step 3: Map barriers and enablers

We then mapped the identified barriers and enablers to at least one theoretical domain and corresponding behaviour change techniques (Table 3). As there are no conclusive links between the domain’s optimism and professional role and modifiable behaviour change techniques, these were not included in our final mapping process [27,28,29]. The corresponding behaviour change techniques to overcome the barriers identified included restricting and adding objects to the environment, providing instructions on how to perform behaviours, and providing information about health consequences [27]. Potential operationalized components to overcome these barriers include information leaflets for healthcare providers which summarize key post-TB health concerns and evidence on incorporating post-TB care, routine educational meetings on post-TB health for healthcare providers and identify post-TB system navigators to coordinate the referral process (Table 3).

Step 4: Evidence synthesis

A review of evidence from Steps 1, 2, and 3 suggests that healthcare providers in British Columbia believe post-TB care should be a simple and systematic process, including the following components:

  1. 1.

    Routinely linking people with TB to a primary care provider if they do not have one

  2. 2.

    Routinely referring people with pulmonary TB for an end-of-treatment chest x-ray and pulmonary function testing

  3. 3.

    Routinely referring people with TB who smoke to a smoking cessation specialist

  4. 4.

    Routinely sending a one-page post-TB information sheet to the patient's primary care provider. This information sheet should include a summary of post-TB health concerns, complications, and recommendations to consider age-appropriate screening for cardiovascular disease, lung cancer, and depression.

To implement these post-TB care components, care navigators should be identified to help coordinate and facilitate access to care. Additionally, information leaflets and checklists for patients and healthcare providers summarizing key post-TB health concerns need to be created to help facilitate discussions. Lastly, routine post-TB team updates and audits are necessary to ensure commitment to post-TB care implementation and provide an opportunity to problem-solve. Key suggested outcome measures included the proportion of patients linked to a primary care provider and the proportion of patients who completed post-treatment chest X-ray and pulmonary function testing. A proposed mechanism for delivering post-TB care based on these findings is presented in Fig. 2.

Fig. 2
figure 2

Proposed mechanism for delivering post-TB care in British Columbia

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Discussion

Results from our study highlight that healthcare providers in British Columbia, Canada believe a post-TB care package should encompass a few measures targeting key healthcare concerns, including (1) routinely linking people with TB to a primary care provider if they do not have one, (2) referring people with pulmonary TB for an end-of-treatment chest x-ray and pulmonary function testing, (3) referring people with TB who smoke to a smoking cessation specialist, and (4) sending a one-page post-TB information sheet to the patient's primary care provider. Our findings also showcase the challenges healthcare providers face in delivering post-TB care, particularly time and resource constraints.

To address these barriers, we propose care navigation services to help streamline and support healthcare providers in providing post-TB care. Additionally, creating physician checklists and culturally appropriate post-TB information leaflets can help facilitate post-TB health discussions between providers and patients. Lastly, we recommend routine post-TB team updates and audits to provide an opportunity to problem-solve and ensure uptake. These proposed solutions were grounded in prior literature linking behaviour change techniques to the TDF domains [27], and then refined based on was is locally appropriate, feasible, and could potentially be implemented as part of a cohesive approach to post-TB care in British Columbia.

One key theme from discussions during the virtual workshops was the importance of care navigation services to help bridge the service gap for populations completing treatment and transitioning out of TB care. Navigation programs were initially developed to address inequitable access to cancer care but have since expanded to provide more holistic person-centred care and to identify and resolve patients' barriers to care [30]. In Canada, the burden of TB is not shared equally; foreign-born individuals and Canadian-born Indigenous peoples continue to be disproportionately affected by TB [31]. These populations are historically underserved and often face barriers to accessing care and navigating a structurally racist healthcare system [32]. Transitions between various healthcare services are potential points for fragmented care, which can be complicated for patients and caregivers [33]. These challenges are further compounded for older adults with multiple comorbidities, new migrants whose primary language is not the language care is provided, or people whom the healthcare system has historically mistreated [32]. Thus, we believe care navigation services should be considered a key component of TB care in British Columbia.

This study demonstrates that leveraging the TDF and a robust multi-method approach can help bridge the gap between post-TB care recommendations and their implementation. The methodology and findings can provide a valuable resource for researchers and practitioners seeking to adopt and implement post-TB care strategies. Moreover, the systematic and iterative process presented in this study can be adapted to various contexts and settings and applied to address similar gaps in adopting and implementing guidelines for other health interventions.

Strengths and limitations

A key strength of our study is its theoretical basis and systematic presentation of post-TB care development in British Columbia. A further strength was our multidisciplinary, collaborative approach, and we ensured that healthcare providers specializing in TB care were involved in different steps. We used workshops with healthcare providers to identify the potential components of post-TB care, and we surveyed healthcare providers to identify barriers and enablers specific to the British Columbia context. Lastly, our research team was multidisciplinary, blending expertise in TB care, primary care, research, and implementation science.

Limitations included a risk of selection bias, as our sample of participants likely consists of highly engaged healthcare providers who already have knowledge of post-TB care. This may have led to underestimating the barriers encountered in post-TB care. Furthermore, with only 23 of 51 questionnaires returned, the limited response rate highlights sample size constraints. The low response rate may have been due to a lack of an honorarium or paid time set aside to participate. Nevertheless, the questionnaire respondents included a diverse group of TB healthcare providers. Thus, we are confident we covered a broad range of relevant aspects.

Our questionnaire results also exhibited relatively low internal consistency, with four of the eight scores demonstrating a Cronbach’s alpha below 0.7. This suggests a moderate ability of the questionnaire to measure the underlying TDF domains accurately. A low internal constituency can compromise the accuracy and validity of the survey results and may also limit our ability to draw reliable conclusions from the survey data. Thus, our survey results should be interpreted with caution. We also only engaged with healthcare providers in British Columbia. Therefore, our findings may only be generalizable to other high-resource, low-TB incidence regions. However, the theory-informed, systematic process we used to obtain our results can be easily adapted to various settings so they can determine locally relevant approaches to post-TB care.

Additionally, the recommended interventions assume there is the capacity for them to take place. In Canada, access to primary care is challenging, with approximately 18% of British Columbians reporting they do not have access to a regular healthcare provider [34, 35]. Thus, a lack of available services, particularly in under-served rural communities, may make it challenging to link TB survivors to primary care providers. Moving forward, we plan to examine the implementation and feasibility of the identified components of post-TB care, including cost-effectiveness data. Given the resource constraints TB programs face, it will also be essential to engage with policymakers and funders of care for strategic alignment and resource allocation for post-TB care.

Lastly, excluding people diagnosed with TB and their caregivers is a significant limitation of our work. Involving people with lived experience can lead to interventions that are more responsive to their needs, as affected communities offer valuable insights into the pressing challenges they face and the optimal approach to addressing them [36, 37]. Thus, the next stage of this research is to explore perceptions of post-TB care among people diagnosed with TB and their caregivers, including the acceptability and uptake of the proposed interventions.

Conclusion

By systematically applying theory and collaborating with team members and knowledge users, we identified healthcare providers specializing in TB care who agree with the need to provide post-TB care as part of comprehensive care in British Columbia. However, a perceived lack of time and resources influences their ability to offer post-TB care effectively. Our results indicate that healthcare providers in British Columbia believe post-TB care should be a simple and systematic process supported by trained care navigators. While post-TB care is complex and multifaceted, our results recommend a practical guide to developing and implementing post-TB care in British Columbia.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

TB:

Tuberculosis

TDF:

Theoretical Domains Framework

BCCDC:

British Columbia Centre for Disease Control

References

  1. World Health Organization. Global Tuberculosis Report 2022. Cited 2023 May 25. Available from: https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2022.

  2. Romanowski K, Baumann B, Basham CA, Khan FA, Fox GJ, Johnston JC. Long-term all-cause mortality in people treated for tuberculosis: a systematic review and meta-analysis. Lancet Infect Dis. 2019;19(10):1129–37.

    Article  PubMed  Google Scholar 

  3. Basham CA, Smith SJ, Romanowski K, Johnston JC. Cardiovascular morbidity and mortality among persons diagnosed with tuberculosis: A systematic review and meta-analysis. PLoS ONE. 2020;15(7):e0235821.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Quaife M, Houben RMGJ, Allwood B, Cohen T, Coussens AK, Harries AD, et al. Post-tuberculosis mortality and morbidity: valuing the hidden epidemic. Lancet Respir Med. 2020;8(4):332–3.

    Article  PubMed  Google Scholar 

  5. Byrne AL, Marais BJ, Mitnick CD, Lecca L, Marks GB. Tuberculosis and chronic respiratory disease: a systematic review. Int J Infect Dis. 2015;1(32):138–46.

    Article  Google Scholar 

  6. Basham CA, Karim ME, Cook VJ, Patrick DM, Johnston JC. Tuberculosis-associated depression: a population-based cohort study of people immigrating to British Columbia, Canada, 1985–2015. Ann Epidemiol. 2021;1(63):7–14.

    Article  Google Scholar 

  7. Allwood BW, van der Zalm MM, Amaral AFS, Byrne A, Datta S, Egere U, et al. Post-tuberculosis lung health: perspectives from the First International Symposium. Int J Tuberc Lung Dis Off J Int Union Tuberc Lung Dis. 2020;24(8):820–8.

    Article  CAS  Google Scholar 

  8. Romanowski K, Oravec A, Billingsley M, Shearer K, Gupte A, Huaman MA, et al. A scoping review of interventions to mitigate common non-communicable diseases among people with TB. Int J Tuberc Lung Dis. 2022;26(11):1016–22.

    Article  CAS  PubMed  Google Scholar 

  9. Migliori GB, Marx FM, Ambrosino N, Zampogna E, Schaaf HS, van der Zalm MM, et al. Clinical standards for the assessment, management and rehabilitation of post-TB lung disease. Int J Tuberc Lung Dis. 2021;25(10):797–813.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Johnston JC, Cooper R, Menzies D. Chapter 5: Treatment of tuberculosis disease. Can J Respir Crit Care Sleep Med. 2022;6(sup1):66–76.

    Google Scholar 

  11. Resar R, Griffin FA, Haraden C, Nolan TW. Using Care Bundles to Improve Health Care Quality. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. Available from: https://www.ihi.org/resources/Pages/IHIWhitePapers/UsingCareBundles.aspx.

  12. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;29(337):a1655.

    Article  Google Scholar 

  13. French SD, Green SE, O’Connor DA, McKenzie JE, Francis JJ, Michie S, et al. Developing theory-informed behaviour change interventions to implement evidence into practice: a systematic approach using the Theoretical Domains Framework. Implement Sci. 2012;7(1):38.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci. 2012;7(1):37.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Lavallée JF, Gray TA, Dumville JC, Cullum N. Preventing pressure injury in nursing homes: developing a care bundle using the Behaviour Change Wheel. BMJ Open. 2019;9(6):e026639.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Beenstock J, Sniehotta FF, White M, Bell R, Milne EM, Araujo-Soares V. What helps and hinders midwives in engaging with pregnant women about stopping smoking? A cross-sectional survey of perceived implementation difficulties among midwives in the North East of England. Implement Sci. 2012;7(1):1–10.

    Article  Google Scholar 

  17. Amemori M, Michie S, Korhonen T, Murtomaa H, Kinnunen TH. Assessing implementation difficulties in tobacco use prevention and cessation counselling among dental providers. Implement Sci. 2011;6(1):50.

    Article  PubMed  PubMed Central  Google Scholar 

  18. BC Centre for Disease Control. TB in British Columbia: Annual Surveillance Report 2016 [Internet]. Vancouver, Canada: BCCDC; 2018 Jul. Cited 2019 Jul 2. p. 1–31. Available from: http://www.bccdc.ca/health-professionals/data-reports/tuberculosis-reports.

  19. Duncan E, O’Cathain A, Rousseau N, Croot L, Sworn K, Turner KM, et al. Guidance for reporting intervention development studies in health research (GUIDED): an evidence-based consensus study. BMJ Open. 2020;10(4):e033516.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Leask CF, Sandlund M, Skelton DA, Altenburg TM, Cardon G, Chinapaw MJM, et al. Framework, principles and recommendations for utilising participatory methodologies in the co-creation and evaluation of public health interventions. Res Involv Engagem. 2019;5(1):2.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Romanowski K, Oravec A, Billingsley M, Shearer K, Gupte A, Huaman MA, et al. A scoping review of interventions to mitigate common non-communicable diseases among people with tuberculosis (In Press). IJTLD.

  22. Murphy MK, Black NA, Lamping DL, McKee CM, Sanderson CF, Askham J, et al. Consensus development methods, and their use in clinical guideline development. Health Technol Assess Winch Engl. 1998;2(3):i–88.

    CAS  Google Scholar 

  23. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;7(348):g1687.

    Article  Google Scholar 

  24. Huijg JM, Gebhardt WA, Crone MR, Dusseldorp E, Presseau J. Discriminant content validity of a theoretical domains framework questionnaire for use in implementation research. Implement Sci. 2014;9(1):11.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Michie S, Johnston M, Francis J, Hardeman W, Eccles M. From Theory to Intervention: Mapping Theoretically Derived Behavioural Determinants to Behaviour Change Techniques. Appl Psychol Int Rev. 2008;57(4):660–80.

    Article  Google Scholar 

  26. RStudio Team. RStudio: Integrated Development for R. RStudio, PBC, Boston, MA; 2020. Available from: http://www.rstudio.com/.

  27. Johnston M, Carey RN, Connell Bohlen LE, Johnston DW, Rothman AJ, De Bruin M, Kelly MP, Groarke H, Michie S. Development of an online tool for linking behavior change techniques and mechanisms of action based on triangulation of findings from literature synthesis and expert consensus. Transl Behav Med. 2021;11(5):1049-65.

  28. Carey RN, Connell LE, Johnston M, Rothman AJ, de Bruin M, Kelly MP, et al. Behavior Change Techniques and Their Mechanisms of Action: A Synthesis of Links Described in Published Intervention Literature. Ann Behav Med Publ Soc Behav Med. 2019;53(8):693–707.

    Google Scholar 

  29. Connell LE, Carey RN, de Bruin M, Rothman AJ, Johnston M, Kelly MP, et al. Links Between Behavior Change Techniques and Mechanisms of Action: An Expert Consensus Study. Ann Behav Med Publ Soc Behav Med. 2019;53(8):708–20.

    Article  Google Scholar 

  30. Valaitis RK, Carter N, Lam A, Nicholl J, Feather J, Cleghorn L. Implementation and maintenance of patient navigation programs linking primary care with community-based health and social services: a scoping literature review. BMC Health Serv Res. 2017;17(1):116.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Mounchili A, Perera R, Lee RS, Njoo H, Brooks J. Chapter 1: Epidemiology of tuberculosis in Canada. Can J Respir Crit Care Sleep Med. 2022;6(sup1):8–21.

    Google Scholar 

  32. Hon. Dr. M.E. Turpel-Lafond. In Plain Sight. Addressing Indigenous-specific Racism and Discrimination in B.C. Health Care Summary Report. 2020. Available from: https://engage.gov.bc.ca/app/uploads/sites/613/2020/11/In-Plain-Sight-Summary-Report.pdf.

  33. Manderson B, Mcmurray J, Piraino E, Stolee P. Navigation roles support chronically ill older adults through healthcare transitions: a systematic review of the literature. Health Soc Care Community. 2012;20(2):113–27.

    Article  PubMed  Google Scholar 

  34. CIHI. Canadian Institute for Health Information. How Canada Compares: Results From the Commonwealth Fund’s 2020 International Health Policy Survey of the General Population in 11 Countries. Ottawa, ON; 2021. Available from: https://secure.cihi.ca/free_products/how-canada-compares-cmwf-survey-2020-chartbook-en.pdf.

  35. Government of Canada SC. Primary health care providers, 2019. 2020 Cited 2022 Nov 22. Available from: https://www150.statcan.gc.ca/n1/pub/82-625-x/2020001/article/00004-eng.htm.

  36. Crawford MJ, Rutter D, Manley C, Weaver T, Bhui K, Fulop N, et al. Systematic review of involving patients in the planning and development of health care. BMJ. 2002;325(7375):1263.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Gooberman-Hill R, Burston A, Clark E, Johnson E, Nolan S, Wells V, et al. Involving Patients in Research: Considering Good Practice. Musculoskeletal Care. 2013;11(4):187–90.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

The authors would like to thank and acknowledge all the individuals who participated in this study.

Funding

The research was funded by BC Lung (2021 LHRG Grant). KR is supported by the Canadian Institutes for Health Research (CIHR) Frederick Banting and Charles Best Doctoral Award (2020–2023). JCJ is supported by a Michael Smith Foundation for Health Research Scholar Award and CIHR (#PJT- 153213).

Author information

Authors and Affiliations

  1. Provincial Tuberculosis Services, British Columbia Centre for Disease Control, Vancouver, BC, Canada

    Kamila Romanowski, Victoria Jane Cook & James Cameron Johnston

  2. Department of Medicine, University of British Columbia, Vancouver, Canada

    Kamila Romanowski, Victoria Jane Cook & James Cameron Johnston

  3. Clinical Prevention Services, British Columbia Centre for Disease Control, Vancouver, BC, Canada

    Mark Gilbert

  4. School of Population and Public Health, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada

    Mark Gilbert

Authors
  1. Kamila Romanowski
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  2. Victoria Jane Cook
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  3. Mark Gilbert
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  4. James Cameron Johnston
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Contributions

KR designed the study, led the workshops, survey development, analysis, interpretation and drafted the manuscript. JCJ oversaw the project and provided a critical review of the study design, findings, interpretation, and manuscript development. VJC and MG provided critical review of the study design, interpretation of the study findings, and manuscript development. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Kamila Romanowski.

Ethics declarations

Ethics approval and consent to participate

Ethical approval of the study was provided by the University of British Columbia Behavioural Research Ethics Board (Behavioural Research Ethics Board Certificate #H22-00732). At the beginning of the virtual workshop and survey, a disclaimer stood in place of a signed formal consent form. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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Supplementary Information

Additional file 1.

GUIDED – a guideline for reporting for intervention development studies.

12913_2023_9835_MOESM2_ESM.pdf

Additional file 2: Supplemental Table 1. Potential post-TB care package components presented during workshops with healthcare providers (Step 1). Supplemental Table 2. Healthcare provider survey questions, their corresponding domain, and the distribution of responses (Step 2). Supplemental Table 3. Demographic characteristics of the healthcare provider survey participants (Step 2). Supplemental Figure 1. Beliefs on which components should be incorporated as part of the post-TB care from the healthcare provider survey (Step 2).

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Romanowski, K., Cook, V.J., Gilbert, M. et al. Using a theory-informed approach to guide the initial development of a post-tuberculosis care package in British Columbia, Canada. BMC Health Serv Res 23, 805 (2023). https://doi.org/10.1186/s12913-023-09835-4

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  • DOI: https://doi.org/10.1186/s12913-023-09835-4

Keywords

BMC Health Services Research

ISSN: 1472-6963

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