Implementing a Scalable Smoke-free Home Intervention in Armenia and Georgia

总结/摘要 低收入和中等收入国家人口面临的差距包括与烟草使用有关的差距 二手烟暴露（SHSe）受烟草使用和性健康和生殖健康影响特别大的两个国家是亚美尼亚 (AM)和格鲁吉亚（GE），分别是全球男性吸烟率第11和第6高的国家（51.5%和55.5%， 分别）。然而，妇女的吸烟率要低得多（1.8%和7.8%）。值得注意的是， 在许多中低收入国家，包括AM和GE，儿童和大多数不吸烟的成年人中，SHSe是家庭。无烟 家庭（SFH）可以减少SHSe，促进戒烟，并可能中断启动;然而，61.4%的AM家庭 GE允许在家中吸烟。因此，促进SFH可能是一种创新的和相对未开发的战略， 在这些国家和其他吸烟率高的低收入国家，研究主要集中在 实施循证干预措施为解决中低收入国家的迫切需求提供了独特的机会 并研究在低资源环境下采用、扩大和维持EBI的主要障碍。这项建议 建立在MPI贝格和Kegler、GE国家疾病控制中心（NCDC）、 AM国家卫生研究所（NIH）和亚美尼亚美国大学（AUA），可追溯到2013年。这些 合作建立了：1）一个强大的以社区为基础的基础设施，用于实施公共卫生计划 在14个社区中使用当地联盟，在我们目前的Fogarty资助的R 01中开发; 2）基于理论的SFHS 干预措施，设计简洁、适应性强，并证明是有效的、可推广的、可扩展的和具有成本效益的 在美国低收入家庭中。目前的提案将战略性地利用我们强大的伙伴关系 与国家公共卫生机构、当地社区动员基础设施和SFH EBI合作， 目标。目标1：我们将调整我们的SFH干预措施，使其在文化上适合AM和GE人群，使用 社区参与的方针和强有力的适应框架和方法，并发展国内能力， 干预措施的传播（通过地方联盟）和交付（通过国家戒烟热线）。目标2：我们将研究 适应性干预（与对照）对AM家庭采用SFH（主要结局）的有效性， GE，使用1型混合有效性-实施RCT（n=550例受试者; 275例/国家），随访 3个月和6个月的评估。目标3：我们将评估干预措施的覆盖范围、采用、实施和维护 潜在的，以及相关的上下文的影响，使用混合方法的过程评价指导下的RE-AIM。我们 一个小组（包括国家公共卫生机构）将利用这些调查结果制定一项可持续性和传播计划 (e.g.,用于扩大规模的干预包装）。这项工作将为适应和实施EBI提供一个强大的模型 用于AM和GE，然后可用于其他国家的这种干预和/或其他行为目标， AM、GE和其他地方的EBI。这项工作将推进我们建立知识库的长期目标， 减少全球与烟草有关的差距的战略，以及在中低收入国家实施和扩大EBI。

SUMMARY/ABSTRACT Among the disparities faced by populations in low- and middle-income countries (LMICs) are those related to tobacco use and secondhand smoke exposure (SHSe). Two countries particularly impacted by tobacco use and SHSe are Armenia (AM) and Georgia (GE), which represent the 11th and 6th highest smoking rates in men globally (51.5% and 55.5%, respectively). However, smoking prevalence is much lower among women (1.8% and 7.8%). Notably, a primary source of SHSe among children and most nonsmoking adults in many LMICs, including AM and GE, is the home. Smoke-free homes (SFHs) can reduce SHSe, promote cessation, and possibly disrupt initiation; however, 61.4% of households in AM and GE allow smoking in the home. Thus, promoting SFHs may be an innovative and relatively untapped strategy for chronic disease prevention in these countries – and in other LMICs with high smoking rates. Research focused on implementing evidence-based interventions (EBIs) offers unique opportunities to address the pressing needs in LMICs and to examine key barriers in the adoption, scale-up, and sustainment of EBIs in low-resource settings. This proposal builds on ongoing collaborations among MPIs Berg and Kegler, the GE National Center for Disease Control (NCDC), the AM National Institute of Health (NIH), and the American University of Armenia (AUA), dating back to 2013. These collaborations have established: 1) a strong community-based infrastructure for implementing public health programs using local coalitions in 14 communities, developed in our current Fogarty-funded R01; and 2) a theory-based SFHs intervention, designed to be brief and adaptable and shown to be effective, generalizable, scalable, and cost-effective among low-income households in the US. The current proposal will strategically capitalize on our strong partnerships with national public health agencies, local community mobilization infrastructure, and SFH EBI to address our specific aims. Aim 1: We will adapt our SFH intervention to be culturally appropriate for the AM and GE populations, using a community-engaged approach and robust adaptation frameworks and methods, and develop in-country capacity for intervention dissemination (via local coalitions) and delivery (via national quitlines). Aim 2: We will examine the effectiveness of the adapted intervention (vs. control) on SFH adoption (primary outcome) among households in AM and GE, using a type 1 hybrid effectiveness-implementation RCT (n=550 participants; 275/country), with follow-up assessments at 3 and 6 months. Aim 3: We will assess intervention reach, adoption, implementation, and maintenance potential, as well as related contextual influences, using a mixed-methods process evaluation guided by RE-AIM. Our team (including national public health agencies) will use these findings to develop a sustainability and dissemination plan (e.g., intervention packaging for scale-up). This work will provide a robust model for adapting and implementing this EBI for AM and GE, which could then be used for this intervention in other countries and/or for other behavioral targets and EBIs in AM, GE, and elsewhere. This work will advance our long-term goals of building the knowledge base informing strategies to reduce tobacco-related disparities globally and the implementation and scale-out of EBIs in LMICs.