Factors associated with successful tobacco use cessation among teachers in Bihar state, India: a mixed-method study.

Although tobacco use is declining in several countries including India (dropping from 35% in 2009-10 to 29% 2016-17 among adults)-it still poses a huge burden on India, as the world's second largest consumer of tobacco products. In Bihar state, with a prevalence of 25%, the Bihar School Teachers Study (BSTS) successfully enlisted teachers as role models for encouraging quitting and changing social norms pertaining to tobacco. The study used a mixed-methods approach to identify factors associated with teachers' quitting. Qualitative data were collected through focus groups with teachers and school principals. Quantitative data were collected through a written survey administered to school personnel post-intervention. Key findings from focus groups were that teachers and principals quit using tobacco and promoted cessation because they wanted to model positive behaviors; specific information about tobacco's harms aided cessation; and the BSTS intervention facilitated a school environment that supported quitting. Survey results indicated teachers who reported knowing people who quit using tobacco in the prior year were far more likely to quit as were teachers who reported that their school's tobacco policy was completely enforced. The combination of qualitative and quantitative data yielded important insights with strong implications for future interventions.

Scaling up a tobacco control intervention in low resource settings: a case example for school teachers in India.

Research on processes of bringing effective tobacco control interventions to scale to increase quit rates among tobacco users is uncommon. This study examines processes to bring to scale one such intervention for school teachers, i.e. Tobacco Free Teacher-Tobacco Free Society (TFT-TFS). This intervention provides a foundation for an effective and low cost approach to promote cessation through schools. The present study was conducted in the states of Bihar and Maharashtra in 2014 using quantitative and qualitative methods. Focus group discussions (FGDs) were analysed using immersion crystallization method. The data presented are from a survey of 291 principals and seven FGDs. This study examined characteristics of principals and teachers, organizational environment, external environmental factors and program characteristics to determine facilitators and barriers for successful dissemination and implementation of the TFT-TFS program. Some facilitators were, incorporation of the program in existing channels like staff meetings and trainings, certification and recognition by the department of education; while some barriers were routine time bound duties (mainly teaching) of teachers and prevalence of tobacco use among teachers and administrators. Principals and teachers expressed a need and high level of interest in the adoption and implementation of the TFT-TFS program in their schools.

Tracking intervention delivery in the 'Tobacco-Free Teachers/Tobacco-Free Society' program, Bihar, India.

In health education and behavior change interventions, process tracking monitors the delivery of an intervention and its receipt to the intended audience. A randomized controlled trial in the state of Bihar, India was conducted to help school teachers become tobacco free through appropriately designed intervention program and delivery system. We describe the results from process tracking of this intervention delivery. The intervention program was centred on six topics delivered in each school through 12 sessions over 6 successive months. The program deliverers recorded the process measures as total number of sessions and program-components implemented (fidelity); time spent conducting sessions (dose) and proportion of teachers attending at least one session (reach). The outcome measures (teachers' exposure to intervention messages and tobacco policy adoption) were assessed post-intervention. All 12 sessions were delivered in 33 out of 36 schools. Thirty-one schools implemented all six program components. In 18 schools, ≥95% of the teachers participated in one or more sessions. Thirty-three schools received 12 or more hours of dose. In 29 schools, 100% teachers reported exposure to all program messages. Tobacco policy was adopted by all schools. Thus, the intervention was generally delivered as planned and it had a positive impact on teachers and schools.

Experiences recruiting Indian worksites for an integrated health protection and health promotion randomized control trial in Maharashtra, India.

This article provides an overview of the recruitment strategies utilized in the Mumbai Worksites Tobacco Control Study, a cluster randomized trial testing the effectiveness of an integrated tobacco control and occupational safety and health program in Indian manufacturing worksites. From June 2012 to June 2013, 20 companies were recruited. Companies were identified using association lists, referrals, internet searches and visits to industrial areas. Four hundred eighty companies were contacted to validate information, introduce the study and seek an in-person meeting with a company representative. Eighty-three company representatives agreed to meet. Of those 83 companies, 55 agreed to a formal 'pitch meeting' with key decision makers at the company. Seventy-seven recruitment 'pitches' were given, including multiple meetings in the same companies. If the company was interested, we obtained a letter of participation and employee roster. Based on this experience, recommendations are made that can help inform future researchers and practitioners wishing to recruit Indian worksites. When compared with recruitment of US manufacturing worksites, recruitment of Indian worksites lacked current industrial lists of companies to serve as a sampling frame, and required more in-person visits, incentives for control companies and more assurances around confidentiality to allow occupational safety and health experts into their worksite.

Impact of organizational policies and practices on workplace injuries in a hospital setting.

OBJECTIVE: This study aimed to assess relationships between perceptions of organizational practices and policies (OPP), social support, and injury rates among workers in hospital units. METHODS: A total of 1230 hospital workers provided survey data on OPP, job flexibility, and social support. Demographic data and unit injury rates were collected from the hospitals' administrative databases. RESULTS: Injury rates were lower in units where workers reported higher OPP scores and high social support. These relationships were mainly observed among registered nurses. Registered nurses perceived coworker support and OPP as less satisfactory than patient care associates (PCAs). Nevertheless, because of the low number of PCAs at each unit, results for the PCAs are preliminary and should be further researched in future studies with larger sample sizes. CONCLUSIONS: Employers aiming to reduce injuries in hospitals could focus on good OPP and supportive work environment.

Alcohol disorders among Asian Americans: associations with unfair treatment, racial/ethnic discrimination, and ethnic identification (the national Latino and Asian Americans study, 2002-2003).

STUDY OBJECTIVE: To examine history of alcohol abuse/dependence disorder in relation to unfair treatment, racial/ethnic discrimination, and ethnic identification among Asian Americans. DESIGN: Weighted multivariate analyses of cross-sectional national survey data predicting lifetime history of alcohol abuse/dependence disorders. SETTING: USA, Asian Americans. PARTICIPANTS: 2007 Asian American adults recruited to the National Latino and Asian American Study (NLAAS; 2002-2003). RESULTS: Controlling for sociodemographic characteristics, Asian Americans who reported experiencing unfair treatment had higher odds of history of alcohol abuse/dependence disorder (OR 5.26, 95% CI 1.90 to 14.56). Participants who reported high levels of ethnic identification had lower odds of history of alcohol abuse/dependence disorders (OR 0.46, 95% CI 0.23 to 0.90). Ethnic identification moderated the influence of racial/ethnic discrimination (p = 0.097). Among participants with low levels of ethnic identification, racial/ethnic discrimination was associated with greater odds of having a history of alcohol disorder compared with those with high levels of ethnic identification. CONCLUSIONS: Social hazards such as unfair treatment and racial/ethnic discrimination should be considered in the development of programmes addressing alcohol disorders among Asian Americans. Interventions that promote ethnic identification in this population may be particularly relevant in mitigating the negative influence of racial/ethnic discrimination on alcohol disorders.

Assessing and intervening on OSH programmes: effectiveness evaluation of the Wellworks-2 intervention in 15 manufacturing worksites.

AIMS: (1) To develop a transparent and broadly applicable method for assessing occupational safety and health (OSH) programmes or management systems; (2) to assess OSH programmes in a sample of manufacturing worksites; and (3) to determine whether a management focused occupational health intervention results in greater improvement in OSH programmes compared to minimal intervention controls. METHODS: OSH programmes were assessed using an adaptation of the US Occupational Safety & Health Administration's 1995 Program Evaluation Profile. Scores were generated from 91 binary indicator variables grouped under four "Essential Elements". Essential Element scores were weighted to contribute to an overall programme score on a 100 point scale. Seventeen large manufacturing worksites were assessed at baseline; 15 sites completed the 16 month intervention and follow up assessments. RESULTS: There was considerable variation in Essential Element scores across sites at baseline as judged by our instrument, particularly in "management commitment and employee participation" and "workplace analysis". Most sites scored highly on "hazard prevention and control" and "training and education". For overall OSH programme scores, most sites scored in the 60-80% range at baseline, with four sites scoring below 60%, suggesting weak programmes. Intervention sites showed greater improvements than controls in the four programme elements and in overall programme scores, with significantly greater improvements in "management commitment and employee participation". CONCLUSIONS: The OSH programme assessment method used is broadly applicable to manufacturing work settings, and baseline profiles suggest needs for improvement in OSH programmes in most such worksites. Despite a small sample size, results showed that sustained management focused intervention can result in improvement in these OSH programme measures.

The feasibility of evaluating a tobacco control intervention for working youth.

OBJECTIVES: To describe the feasibility of implementing evaluation methods for a worksite tobacco control intervention for teens. Indicators of feasibility included employment stability, response rates to multiple surveys, and self reported 30 day smoking. DESIGN: Grocery stores that were part of a single chain were randomised to four intervention stores and five control stores as part of the SMART project, a phase II methods development study designed to reduce smoking among working adolescents. SUBJECTS: Data on smoking in the last 30 days and employment patterns were collected from working teens aged 15-18 years at seven data points over the 12 month intervention period using cross sectional surveys. RESULTS: Data on employment stability indicate that employee turnover rates averaged 21% over the seven administrations. Response rates for the seven surveys ranged from 43-77% and were slightly greater in the control stores than the interventions stores (71% v 59%, p = 0.06). Mean current smoking at the individual store level ranged from 9-32% and there was a negative correlation between smoking prevalence and response rate by survey and by store (-0.029, p = 0.03). Among smokers who completed at least two surveys, there were no significant differences between intervention and control store on changes in the frequency of smoking. CONCLUSIONS: Evaluating a tobacco control intervention in the grocery store setting requires multiple survey assessments to monitor changes in smoking among adolescents. Strategies are needed to maintain high response rates and increase the number of multiple responses from eligible teens.

Social influences, social norms, social support, and smoking behavior among adolescent workers.

PURPOSE: To examine the relationships between worksite interpersonal influences and smoking and quitting behavior among adolescent workers. DESIGN: The cross-sectional survey assessed factors influencing tobacco use behavior. SETTING: During the fall of 1998, data were collected from 10 grocery stores in Massachusetts that were owned and managed by the same company. SUBJECTS: Eligible participants included 474 working adolescents ages 15 to 18. Eighty-three percent of workers (n = 379) completed the survey. MEASURES: The self-report questionnaire assessed social influences, social norms, social support, friendship networks, stage of smoking and quitting behavior, employment patterns, and demographic factors. RESULTS: Thirty-five percent of respondents were never smokers, 21% experimental, 5% occasional, 18% regular, and 23% former smokers. Using analysis of variance (ANOVA), results indicate that regular smokers were 30% more likely than experimental or occasional smokers to report coworker encouragement to quit (p = .0002). Compared with regular smokers, never smokers were 15% more likely to report greater nonacceptability of smoking (p = .01). chi 2 tests of association revealed no differences in friendship networks by stage of smoking. CONCLUSIONS: These data provide evidence for the need to further explore social factors inside and outside the work environment that influence smoking and quitting behavior among working teens. Interpretations of the data are limited because of cross-sectional and self-report data collection methods used in one segment of the retail sector.

The effect of social desirability trait on self-reported dietary measures among multi-ethnic female health center employees.

PURPOSE: To evaluate the effect of social desirability trait, the tendency to respond in a manner consistent with societal expectations, on self-reported fruit, vegetable, and macronutrient intake. METHODS: A 61-item food frequency questionnaire (FFQ), 7-item fruit and vegetable screener, and a single question on combined fruit and vegetable intake were completed by 132 female employees at five health centers in eastern Massachusetts. Intake of fruit and vegetables derived from all three methods and macronutrients from the FFQ were fit as dependent variables in multiple linear regression models (overall and by race/ethnicity and education); independent variables included 3-day mean intakes derived from 24-hour recalls (24HR) and score on the 33-point Marlowe-Crowne Social Desirability scale (the regression coefficient for which reflects its effect on estimates of dietary intake based on the comparison method relative to 24HR). RESULTS: Results are based on the 93 women with complete data and FFQ-derived caloric intake between 450 and 4500 kcal/day. In women with college education, FFQ-derived estimates of total caloric were associated with under-reporting by social desirability trait (e.g., the regression coefficient for total caloric intake was -23.6 kcal/day/point in that group versus 36.1 kcal/day/point in women with education less than college) (difference = 59.7 kcal/day/point, 95% confidence interval (CI) = 13.2, 106.2). Except for the single question on which women with college education tended to under-report (difference =.103 servings/day/point, 95% CI = 0.003, 0.203), there was no association of social desirability trait with self-reported fruit and vegetable intake. CONCLUSIONS: The effect of social desirability trait on FFQ reports of macronutrient intake appeared to differ by education, but not by ethnicity or race. The results of this study may have important implications for epidemiologic studies of diet and health in women.

Promoting breast and cervical cancer screening at the workplace: results from the Woman to Woman Study.

OBJECTIVES: This article reports findings from a peer-delivered intervention designed to increase use of breast and cervical cancer screening. METHODS: Twenty-six worksites were randomly assigned to the intervention or comparison group. The 16-month intervention consisted of group discussions, outreach, and educational campaigns. Data were collected from a random sample of women employees stratified by age (baseline n = 2943; final n = 2747). Cross-sectional analyses were conducted to evaluate the impact of the intervention on screening behaviors. RESULTS: Relative to comparison worksites, the intervention group experienced greater increases in the percentage of women who reported a recent mammogram (7.2% vs 5.6%), clinical breast examination (5.8% vs 2.1%), and Papanicolaou (Pap) test (4.7% vs 1.9%). After worksite cluster and age strata were controlled for, the observed increase in Pap tests was significantly greater in the intervention group (odds ratio [OR] = 1.28; 95% confidence interval [CI] = 1.01, 1.62); however, differences in mammography screening rates (OR = 1.14; 95% CI = 0.90, 1.44) and clinical breast examination (OR = 1.19; 95% CI = 0.96, 1.49) were not statistically significant. CONCLUSIONS: Intervention activities produced a modest increase in cervical cancer screening, but they did not accelerate breast cancer screening rates above the observed secular trend.

Reducing risk for cardiovascular disease in uninsured women: combined results from two WISEWOMAN projects.

OBJECTIVE: to evaluate the effectiveness of a cardiovascular disease (CVD) risk factor reduction program for financially disadvantaged women. The program included cholesterol and blood pressure assessments and tailored physical activity and nutrition interventions. METHODS: Women who attended selected National Breast and Cervical Cancer Early Detection Program sites in North Carolina and Massachusetts received either enhanced physical activity and nutrition interventions (EI) or minimum interventions (MI). The effectiveness of EI was assessed by pooling data from the North Carolina and Massachusetts projects after 1 year, and a mixed models analysis of covariance was used to compare changes in CVD risk factors across groups. RESULTS: The blood pressure, total cholesterol, and high-density lipoprotein cholesterol profiles of both groups improved, body weight was maintained, and smoking declined. The 10-year estimated coronary heart disease death rate (per 1,000 women) at baseline was 64.8 for the El group and 61.9 for the MI group. The rate declined by 3.5 deaths per 1,000 for the EI and 0.7 per 1,000 for the MI. Although the decline was statistically significant for the EI group, the difference between groups was not significant. CONCLUSION: Further lifestyle intervention research targeting financially disadvantaged women is needed.

Underutilizers of mammography screening today: characteristics of women planning, undecided about, and not planning a mammogram.

Using concepts from the Precaution Adoption Process Model, we identified behavioral factors, sociodemographic and psychosocial variables, and beliefs about breast cancer that discriminated among women at different stages with regard to their intention to obtain mammography screening. An independent survey company conducted telephone interviews with 2,507 women aged 50 to 80 who were identified as underutilizers of mammography screening. Each underutilizer was assigned to one of three stages with regard to intention to get a mammogram: (a) definitely planning, (b) thinking about, and (c) not planning. Estimated actual risk of breast cancer, perceived risk to breast cancer, worry about breast cancer, and fear of learning from a mammogram that one has breast cancer were variables found to be significantly associated with intention to obtain a mammogram for several subgroups of underutilizing women. There are significant behavioral and psychosocial variables, beliefs and feelings about breast cancer, and demographic characteristics that distinguish underutilizing women at various stages with regard to intention to obtain mammography screening. Our findings provide new information that could help the health care professional motivate women who are not planning to utilize this preventive health measure to become regular utilizers.

Promoting mammography: results of a randomized trial of telephone counseling and a medical practice intervention.

BACKGROUND: Despite widespread promotion of mammography screening, a distinct minority of women have remained underusers of this effective preventive measure. We sought to measure the effects of barrier-specific telephone counseling (BSTC) and a physician-based educational intervention (MD-ED) on mammography utilization among underusers of mammography screening. DESIGN: This was a randomized controlled trial. Women meeting criteria for mammography underuse at baseline (grouped by practice affiliation) were randomized to a reminder control condition (RC group received annual mailed reminders), BSTC or MD-ED interventions and followed for 3 years. Underuse was defined by failure to get two annual or biannual mammograms over a 2- to 4-year period prior to a baseline survey. PARTICIPANTS AND SETTING: The study included 1655 female underusers of mammography aged 50-80 years who were members of two health maintenance organizations (HMO) in central Massachusetts. INTERVENTIONS: BSTC consisted of periodic brief, scripted calls from trained counselors to women who had not had a mammogram in the preceding 15 months. Women could receive up to three annual calls during the study. MD-ED consisted of physician and office staff trainings aimed at improving counseling skills and office reminder systems. MAIN OUTCOME MEASURE: Self-report of mammography use during the study period was the main outcome measure. Regular use was defined as > or =1 mammogram every 24 months. RESULTS: Forty-four percent in each intervention group became regular users compared to 42% in the RC group. Among subjects who had prior but not recent mammograms at baseline, BSTC was effective (OR=1.48; 95% CI=1.04; 2. 10), and MD-ED marginally effective (OR=1.28; 95% CI=0.88, 1.85). Most recent users at baseline and few never users became regular users (61% and 17%, respectively) regardless of intervention status. CONCLUSIONS: Among mammography underusers BSTC modestly increases utilization for former users at a reasonable cost ($726 per additional regular user).

Smoking cessation counseling with pregnant and postpartum women: a survey of community health center providers.

OBJECTIVES: This study assessed providers' performance of smoking cessation counseling steps with low-income pregnant and postpartum women receiving care at community health centers. METHODS: WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) program staff, obstetric clinicians, and pediatric clinicians at 6 community health centers were asked to complete surveys. Smoking intervention practices (performance), knowledge and attitudes, and organizational facilitators were measured. Factors associated with performance were explored with analysis of variance and regression analysis. RESULTS: Performance scores differed significantly by clinic and provider type. Providers in obstetric clinics had the highest scores and those in pediatric clinics had the lowest scores. Nurse practitioners and nutritionists had higher scores than other providers. Clinic type, greater smoking-related knowledge, older age, and perception of smoking cessation as a priority were independently related to better counseling performance. CONCLUSIONS: Mean performance scores demonstrated room for improvement in all groups. Low scores for performance of steps beyond assessment and advice indicate a need for emphasis on the assistance and follow-up steps of national guidelines. Providers' own commitment to helping mothers stop smoking was important.

Local labor unions' positions on worksite tobacco control.

OBJECTIVES: This report describes local unions' positions on tobacco control initiatives and factors related to these positions. METHODS: A national random sample of local union leaders was surveyed by telephone. RESULTS: Forty-eight percent of local unions supported worksite smoking bans or restrictions, and only 8% opposed both a ban and a restriction. CONCLUSIONS: Support for tobacco control initiatives among local unions was higher than might be expected on the basis of previous evidence. Engaging unions in smoking policy formation is likely to contribute to the larger public health goal of reducing smoking and exposure to second-hand smoke among workers.

The effectiveness of using standardized patients to improve community physician skills in mammography counseling and clinical breast exam.

BACKGROUND: Traditional didactic continuing education is relatively ineffective in improving physicians' clinical skills. We hypothesized that a centralized course including small group workshops utilizing standardized patients could improve clinical skills for a reasonable cost. METHODS: We designed a 5-h course aimed at improving physicians' counseling skills (re: screening mammography) and clinical breast exam (CBE) skills. The course included lectures, demonstrations, and small group skills sessions utilizing standardized patients and was offered to 156 typical community-based primary care physicians. Pre- and postcourse evaluation included in-office assessments of physician CBE and counseling performance by standardized patients and a written test of knowledge and attitudes. RESULTS: A total of 54.5% of eligible physicians participated. They improved modestly in only one of three areas of counseling skills measured (providing counseling appropriate to the patient's readiness to accept mammography, P = 0.01). The overall CBE score increased substantially from 24.8 to 34.7 (P < 0.0001). Knowledge in all areas measured and confidence in counseling patients also increased. The basic course cost $202 per physician trained. CONCLUSIONS: Most community-based primary care physicians may find small group training and in-office evaluation involving standardized patients acceptable. Such training may be more effective in improving physical exam skills than complex communication skills.

The relationship between social network characteristics and breast cancer screening practices among employed women.

This study examined the relationship between social network characteristics and breast cancer screening practices among employed women. We hypothesized that larger social networks, higher levels of support from networks, and stronger social influences to undergo screening would be positively associated with regular utilization of mammograms and clinical breast examinations. Data were collected from women aged 52 and over who were employed in 27 worksites (N = 1,045). Social network characteristics, breast cancer screening practices, and sociodemographic factors were assessed in a self-administered survey. Bivariate analyses revealed that social influences were significantly associated with regular screening; social support was only marginally associated with regular screening; and social network size was not at all associated. In multivariate analyses, only the perception that screening is normative among one's peers was predictive of regular screening. Provider recommendation was the single most potent predictor of regular screening. These findings provide support for the importance of social norms in motivating women to adhere to screening guidelines. In addition, they underscore the potent impact of provider recommendations on women's screening practices.