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

吸入他人的烟雾被称为被动吸烟;也被称为环境或二手烟。二手烟（SHS）含有4,000种化学物质，对非吸烟者来说是一种严重的健康危害。据估计，全世界每年有60多万人死于SHS。SHS引起的疾病总负担中有很大一部分是由于哮喘、胸部感染和肺癌等肺部疾病。妇女和儿童受影响最严重; 47%的SHS暴露死亡发生在成年女性和28%的儿童中。认识到SHS是一种公共健康威胁，大多数国家都禁止在封闭的公共场所吸烟，这大大减少了成年人接触SHS的机会。然而，对于大多数不吸烟的妇女和儿童来说，汽车和家庭仍然是他们在SHS中最有可能呼吸的地方。保护他们免受SHS的唯一可能的方法是使汽车和家庭完全无烟。在过去的几年里，我们一直在与穆斯林社区合作，开发和测试一种以社区为基础的干预措施，称为“无烟家庭”（SFH）。我们在清真寺培训伊玛目（穆斯林信仰领袖），鼓励他们的会众积极改变吸烟行为。伊玛目在学习圈、定期祈祷和古兰经课上激发讨论。通过我们的试点工作，我们发现，在适当的支持下，清真寺是促进健康的合适场所，伊玛目愿意传递无烟信息。此外，我们还开发了使用廉价高效的家庭安装仪表测量室内空气质量（IAQ）的技术。在一项试点研究中，我们已经证明，室内空气质量反馈也可以激励家庭吸烟行为的变化。受英国试点工作的启发，我们现在建议在孟加拉国进行一项大型研究，SHS是一个主要的公共卫生问题，也是烟草控制政策制定的优先事项。通过我们在孟加拉国这一领域多年的工作，我们与当地社区和决策者建立了合作关系。在进行主要研究之前，我们将根据孟加拉国的情况调整SFH。改编工作将参考在达卡与社区成员和伊玛目进行的访谈和讨论的结果。我们希望研究在有或没有室内空气质量反馈的情况下，SFH在减少家庭中SHS暴露方面的有效性。我们也有兴趣看看干预是否改善了他们的肺部健康，一般生活质量，并减少卫生服务的使用。为了准确回答这些重要问题，我们将在其集水区招募45个清真寺和1800个家庭。我们将随机分配清真寺到三个分支。第一分支的清真寺将接受SFH培训，其会众将收到来自其社区的房屋样本的室内空气质量反馈。第2组的人只接受SFH培训，第3组的清真寺将提供常规服务。我们还将使用客观的测量方法，包括测试室内空气质量，以评估我们的干预措施是否减少了家庭中的SHS暴露。其他措施将包括问卷调查，以记录呼吸道症状，如咳嗽，喘息和规模，以衡量生活质量。我们将使用国际公认的标准进行上述所有测量。在接下来的六个月里，我们将定期重复这些评估。与此同时，我们亦会进行经济分析，评估是否物有所值。其后，我们亦会评估如何以最佳方法推行食物环境卫生署，并把有关计划推广。在这部分研究中，我们将（a）估计扩大干预措施的可能成本和影响，（B）开发一个简单的实施监测工具，（c）调查实施和扩大干预措施的可能障碍和机会，以及（d）如何最好地与社区和决策者合作，克服这些障碍，最大限度地利用这些机会。

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.