A realist evaluation of the implementation of a national tobacco control program and policy in India.

There is a growing interest in studying and unpacking implementation of policies and programmes as it provides an opportunity to reduce the policy translation time lag taken for research findings to translate to policies and get implemented and understand why policies may fail. Realist evaluation is a theory-driven approach that embraces complexity and helps to identify the mechanisms generating the observed policy outcomes in given context. We aimed to study facilitators and barriers while implementing the Cigarettes and Other Tobacco Products Act, 2003 (COTPA) a comprehensive national tobacco control policy, and the National Tobacco Control Programme (NTCP), 2008 using realist evaluation. We developed an initial program theory (IPT) based on a realist literature review of tobacco control policies in Low- and Middle-Income Countries (LMICs). Three diverse states -Kerala, West Bengal, and Arunachal Pradesh- with varying degree of implementation of tobacco control law and program were chosen as case studies. Within the three selected states, we conducted in-depth interviews with 48 state and district-level stakeholders and undertook non-participant observations to refine the IPT. Following this, we organized two regional consultations covering stakeholders from 20 Indian states for a second iteration to further refine the program theory. A total of 300 Intervention-Context-Actor-Mechanism-Outcome (ICAMO) configurations were developed from the interview data, which were later synthesized into state-specific narrative program theories for Kerala, West Bengal and Arunachal Pradesh. We identified five mechanisms: collective action, felt accountability, individual motivation, fear, and prioritization that were (or were not) triggered leading to diverse implementation outcomes. We identified facilitators and barriers to implementing the COTPA and the NTCP, which have important research and practical implications for furthering the implementation of these policies as well as implementation research in India. In the future, researchers could build on the refined program theory proposed in this study to develop a middle-range theory to explain tobacco control policy implementation in India and other LMICs.

Implementation Strategies for Maternal Near-Miss Case Reviews in LICs and LMICs: A scoping review protocol.

Background: Maternal mortality remains a persistent public health concern despite significant strides in reduction over the past few decades, with a global maternal mortality ratio (MMR) of 223 deaths per 100,000 live births in 2020, indicating a 34.3% decline over 20 years, with Low income countries (LICs) and Lower Middle-Income Countries (LMICs) bearing the major burden. Effective implementation of facility-based near-miss case reviews (NMCR), endorsed by the World Health Organization (WHO), faces challenges hindering progress, making exploring implementation strategies through a scoping review essential. This scoping review aims to identify and characterize implementation strategies employed in Low and Lower Middle- Income Countries to facilitate the implementation of facility-based NMCR. Methods: The scoping review will follow Arksey and O'Malley's methodological framework, involving five stages: identifying the research question, selecting relevant studies, selecting data, charting, and summarizing the results. Electronic databases like PubMed, Embase, Web of Science, EBSCOhost - CINAHL Ultimate, and Ovid MEDLINE will be searched, supplemented by citation tracking. Rayyan will be used to screen and remove duplicates, with data charting conducted using Google Sheets. Two independent reviewers will conduct blinded screening, eligibility assessment, and inclusion phases. Reviewers will conduct Systematic data extraction independently using piloted forms, with discrepancies resolved through team discussion and consensus. Results: The review will identify and characterize implementation strategies employed to facilitate the implementation of facility-based near-miss case reviews in LICs and LMICs. Conclusions: The findings of this review will contribute to the understanding of implementing strategies for facility-based NMCR in LICs and LMICs. The review can help in designing interventions/programs to reduce maternal mortality and knowledge products.

Shifting the gaze on implementation: examining the association between the implementation of tobacco control laws and prevalence of tobacco using data from a nationally representative survey.

BACKGROUND: Tobacco use and the associated health burden is a cause of concern in India and globally. Despite several tobacco control policies in place, their sub-optimal and variable implementation across Indian states has remained a concern. Studies evaluating the real-world implementation of policies such as Cigarettes and Other Tobacco Products (COTPA) or National Tobacco Control Program (NTCP) in India and its association with reductions in tobacco use are limited. In this paper, we analyse data from a nationally representative survey to examine how policy implementation is associated with the tobacco use prevalence in India. METHODS: We analysed data from the Global Adult Tobacco Survey (GATS 2016-17) India using multivariable logistic regression. The dependent variables were the use of smoked tobacco, smokeless tobacco, and tobacco in any form. The independent variables were proxies of implementation of the COTPA and the NTCP. We followed a step-wise backward elimination technique to reach the best fit models. RESULTS: People exposed to no-smoking signages had lower odds of using tobacco (OR = 0.70, p < 0.001). People exposed to second-hand smoke (OR = 1.51, p < 0.001) and tobacco product advertisements (OR = 1.23, p < 0.001) had greater odds of using tobacco. Exposure to tobacco advertisements was associated with higher odds of using smokeless tobacco (OR = 1.23, p < 0.001), and smoked (OR = 1.33, p < 0.001) forms of tobacco. CONCLUSION: We find significant association between the implementation of tobacco control laws/programs and tobacco use in India. Our findings highlight the potential that policy implementation holds in reducing population-level tobacco use thus drawing attention towards the implementation phase of policies. The findings have implications on prioritising enforcement of specific tobacco control measures such as smokefree laws, modifying COTPA signages to encompass all tobacco products including against smokeless tobacco use and strengthening indirect advertising restrictions. Future research could focus on developing and validating predictors specific to policy implementation to support policy evaluation efforts.

How does Indian news media report smokeless tobacco control? A content analysis of the gutka ban enforcement.

Smokeless tobacco (SLT) products like gutka and paan masala are a growing public health crisis in India. Despite enacting a ban-the highest form of regulation-little is known about implementation progress. The purpose of this study was to look at how enforcement of gutka ban is covered in Indian news media and if media is a reliable source of data. We conducted a content analysis of online news reports (n = 192) from 2011 to 2019. News characteristics such as name and type of publication, language, location, slant and beat coverage, visuals, and administrative focus were quantified. Similarly, news contents were inductively coded to examine dominant themes and the implementation landscape. We found that coverage was initially low but increased after 2016. Overall, news reports were in favor of the ban. Five leading English newspapers covered the majority of the ban enforcement reports. Prominent themes like consumption, health hazards, tobacco control responses, impact on livelihoods, and illicit trade were drawn from the textual analysis as the main arguments in relation to the ban. Gutka is largely seen as an issue of crime reflected by the contents, sources, and frequent use of pictures depicting law enforcement. The interconnected distribution channels of the gutka industry hindered enforcement, highlighting the need to study the complexities of regional and local SLT supply chains.

Coproducing tobacco control knowledge: Using virtual platforms to strengthen implementation in India.

Tobacco control is complex and multidimensional. In India, 266.8 million adults use tobacco in some form, with local contextual factors shaping its consumption, production, and trade. Actors have a stake in tobacco represent different sectors; with varying priorities, responding to different ideas, and exerting varying levels of influence often make it difficult to work collaboratively on tobacco control-related issues. Through online networking platforms such as webinars, we emphasize how coproduction of tobacco control knowledge enables participation, prioritizes multisectoral strategies, and enhances tobacco control leadership among policymakers and implementers in their settings. Coproduction of knowledge between and across stakeholders with a focus on "how to" implement tobacco control policies can leverage in negotiating and supplementing the policy implementation process.

LifeFirst: Impact of a school-based tobacco and supari cessation intervention among adolescent students in Mumbai, India.

INTRODUCTION: The youth are a vulnerable population-group for tobacco-related harms. Schools are an excellent setting for health promotion; yet there is a dearth of school-based cessation interventions, rarely evaluated for their impact. Here, we assess the impact of the LifeFirst program: an ongoing tobacco and supari (areca nut) cessation intervention delivered to students from corporation schools in Mumbai city. METHODS: We used a prospective quasi-experimental design with an intervention and a control arm embedded within an ongoing LifeFirst program in select schools. We used a difference-in-difference analysis with baseline and end-line surveys to assess the program's impact on students' knowledge about harms, students' refusal skills, and prevalence of tobacco/supari use. We report our work using the TREND statement checklist. RESULTS: A total of 959 students registered in the LifeFirst program. In our analysis, we included 827 students who completed both the baseline and end-line surveys. Postintervention, we found both tobacco and supari use reduced substantially among the intervention group while tobacco use increased among the control group. The difference-in-difference estimates show a statistically significant reduction of 17.9 and 38.1 percentage points in the intervention group for tobacco and supari use respectively, beyond the reduction in the control group. CONCLUSIONS: The LifeFirst program was successful in reducing tobacco and supari use among the study participants and protected students in the intervention group against new uptake of tobacco. It helped improve knowledge score and refusal skills among students. Implementation and evaluation of similar school-based programs should be considered as part of a multi-strategy approach to reducing tobacco use among young people.

Healthcare delivery in India amid the Covid-19 pandemic: Challenges and opportunities.

In India, the Covid-19 pandemic has thrown open challenges on multiple fronts: (a) the reconfiguration of care in hospitals, in response to Covid-19, has led to many patients suffering non-Covid conditions having to delay their treatment, and (b) the lockdown which though necessary has affected people unequally, some being much worse-off than others. This article unpacks the impact of Covid-19 on healthcare systems in India by raising moral and ethical questions about the plight of patients with other medical conditions while accessing care. This article also proposes a set of actions by which healthcare systems can address Covid and non-Covid related healthcare needs.

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From Policy to Practice: Lessons from Karnataka about Implementation of Tobacco Control Laws.

BACKGROUND: Tobacco use accounts for eight to nine lakh adult deaths annually in India. India enacted a national legislation "Cigarettes and Other Tobacco Products Act, 2003" (COTPA) to protect health of non-smokers and reduce tobacco consumption. However, even a decade after enacting this law, its implementation remains suboptimal and variable across the Indian states. Karnataka has shown leadership on this front by enacting a state law and implementing COTPA at (sub-) district levels. We, therefore, aim to analyze COTPA implementation processes in Karnataka to understand how COTPA can be effectively implemented. METHODS: We developed a case study of COTPA implementation in Karnataka using reports from health, police, education, and transport departments as well as government orders and media reports related to COTPA. We analyzed these data to map and understand the role played by the government agencies in COTPA implementation. We used the proportion of the districts reporting COTPA violations, the number of COTPA violations cases reported, and the proportion of schools reporting compliance with COTPA as proxy measures for COTPA implementation. RESULTS: We found that five government agencies (police, education, health, transport, and urban development) played a major role in COTPA implementation. All the police districts reported COTPA violations with 59,594 cases in a year (April 2013-March 2014). Three of the district anti-tobacco cells and two of the transport divisions reported 1130 and 14,543 cases of COTPA violations, respectively, in the same year. In addition, 84.7% of schools complied with signage requirements of COTPA. COTPA reporting was made part of the reporting systems within health, police, and education departments. The health department created awareness on tobacco harms and COTPA. CONCLUSIONS: COTPA implementation in Karnataka was made possible through integrating COTPA implementation within structure/functions of five government agencies.

Mycological and histological associations of Candida in oral mucosal lesions.

The present study aimed to assess the presence and level of colonization of Candida in patients with oral mucosal lesions, to determine the presence or absence of candidal hyphae in biopsy specimens and to correlate the degree of epithelial dysplasia with the number of colony-forming units of Candida. We performed a prospective study including 50 patients diagnosed as having oral potentially malignant and malignant disorders. These patients had lesions such as leukoplakia, lichen planus, lichenoid reaction, verrucous carcinoma and oral squamous cell carcinoma. An oral swish with 10 mL of normal saline was performed, and this was collected in a sterile plastic container. Candidal colony-forming units were assessed in the specimen. This was followed by a biopsy of the lesion, which was sent for histopathologic examination for dysplasia and severity, and to assess the presence or absence of candidal hyphae. The results of the present study revealed a correlation between higher Candida colonization and increasing severity of dysplasia. An effort was made to correlate Candida by histologic and mycologic means with epithelial dysplasia. If such a correlation is strongly established, then the importance of antimycotic therapy can be emphasized to avoid deterioration.

Prevalence and correlation of oral lesions among tobacco smokers, tobacco chewers, areca nut and alcohol users.

INTRODUCTION: The incidence of oral premalignant and malignant lesions is on the rise due to an increased number of people taking in tobacco and alcohol related habits. MATERIAL AND METHODS: 1028 patients with tobacco, alcohol and areca nut habits attending our Department of Oral Medicine and Radiology formed the study sample. An interviewer based questionnaire was used to record the habit details. All the patients were then examined clinically for the presence of lesions. Chi square and Fisher exact tests were used to assess the statistical significance of the study parameters. RESULTS: Males had a higher prevalence and comprised 87.9% of the sample. The commonest habit in this study sample was smoking (39.2%) followed by smokeless tobacco use (28.1%). Out of the 1028 patients with habits 40% had no clinically detectable changes in their mucosa. Of the mucosal changes leukoplakia (14%) was the commonest. CONCLUSIONS: This study provided information about the habit trends in the patients visiting this institution. The study may serve as a useful tool in educating the patients about the deleterious effects of oral tobacco, alcohol and betel exposure.