Muslim Communities Learning About Second-hand Smoke in Bangladesh (MCLASS II): An effectiveness-implementation hybrid study

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Breathing in other people's smoke is called passive smoking; also referred to as environmental or second-hand smoking. Second-hand smoke (SHS) contains 4,000 chemicals, and is a serious health hazard to non-smokers. SHS is estimated to cost more than 600,000 lives per year, worldwide. A large proportion of the overall burden of diseases due to SHS is due to lung diseases such as asthma, chest infections and lung cancer. Women and children are worst affected; 47% of deaths from SHS exposure occur in female adults and 28% in children. Recognising SHS as a public health threat, most countries have introduced bans on smoking in enclosed public spaces, which has significantly reduced adults' exposure to SHS. However, for most non-smoking women and children, cars and homes remain the most likely places for them to breathe in SHS. The only possible way to protect them from SHS is to make cars and homes completely smoke free.For the last few years, we have been working with Muslim communities to develop and test a community-based intervention called, 'Smoke Free Homes' (SFH). We train Imams (Muslim faith leaders) based in mosques to encourage their congregations to make a positive change in their smoking behaviours. Imams stimulate discussions during study circles, in-between regular prayers and during Quran classes. Through our pilot work, we found that with proper support mosques are a suitable place for promoting health and Imams are willing to deliver smoke-free messages. In addition, we have also developed technology to measure Indoor Air Quality (IAQ) using a cheap and efficient home installation meter. In a pilot study, we have demonstrated that IAQ feedback can also motivate changes in smoking behaviours in homes.Inspired by our pilot work in the UK, we now propose a large study in Bangladesh where SHS is a major public health problem and a priority for policy making in tobacco control. Through our work in Bangladesh in this area for several years, we have established collaborations with local communities and policy makers. Before carrying out the main study, we will adapt SFH to Bangladesh context. The adaptation will be informed by the findings of the interviews and discussions with community members and Imams in Dhaka. We wish to examine how effective is SFH, with or without IAQ feedback, in reducing exposure to SHS in homes. We are also interested to see if the intervention improves their lung health, general quality of life, and reduce health service use. To provide accurate answers to these important questions, we will recruit a total of 45 Mosques and 1800 households in their catchment area. We will randomly allocate mosques to three arms.Mosques in arm 1, will receive training on SFH and their congregation will receive IAQ feedback on a sample of homes from their community. Those in arm 2, will only receive training on SFH and arm 3 mosques will have usual services. We will also use objective measurements including testing IAQ to assess whether our intervention has reduced SHS exposure in homes. Other measures will include questionnaires to record respiratory symptoms such as cough, wheeze and scales to measure quality of life. We will undertake all the measurements as described above using internationally agreed standards. Over the following six-months, we will repeat these assessments at regular intervals. In parallel, using an economic analysis we will also assess whether SFH with or without IAQ is value for money.Subsequently, we will also assess how best to implement SFH with or without IAQ feedback and bring it to scale. For this part of the study, we will (a) estimate the likely costs and effects of scaling up the intervention, (b) develop a simple implementation monitoring tool, (c) investigate likely obstacles to and opportunities for implementing and scaling up the intervention, and (d) how best to work with communities and policy makers to overcome these obstacles and maximize such opportunities.