Smoking-related psychosocial beliefs and justifications among smokers in India: Findings from Tobacco Control Policy (TCP) India Surveys.

BACKGROUND: Previous research in high-income countries (HICs) has shown that smokers reduce their cognitive dissonance through two types of justifications over time: risk minimizing and functional beliefs. To date, however, the relationship between these justifications and smoking behaviors over time has limited evidence from low- and middle-income countries. This study examines these of justifications and their relation to quitting behavior and intentions among smoking tobacco users in India. METHODS: The data are from the Tobacco Control Policy (TCP) India Survey, a prospective cohort of nationally representative sample of tobacco users. The respondents include smoked tobacco (cigarettes and bidi) users (n = 1112) who participated in both Wave 1 (W1; 2010-2011) and Wave 2 (W2; 2012-2013) surveys. Key measures include questions about psychosocial beliefs such as functional beliefs (e.g., smoking calms you down when you are stressed or upset) and risk-minimizing beliefs (e.g., the medical evidence that smoking is harmful is exaggerated) and quitting behavior and intentions at Wave 2. FINDINGS: Of the 1112 smokers at W1, 78 (7.0%) had quit and 86 (7.8%) had intentions to quit at W2. Compared to W1, there was a significant increase in functional beliefs at W2 among smokers who transitioned to mixed use (using both smoking and smokeless tobacco) and a significant decrease among those who quit. At W2, smokers who quit held significantly lower levels of functional beliefs, than continuing smokers, and mixed users ((M = 2.96, 3.30, and 3.93, respectively, p < .05). In contrast, risk-minimizing beliefs did not change significantly between the two waves. Additionally, higher income and lower functional beliefs were significant predictors of quitting behavior at W2. CONCLUSION: These results suggest that smokers in India exhibit similar patterns of dissonance reduction as reported in studies from HICs: smokers who quit reduced their smoking justifications in the form of functional beliefs, not risk-minimizing beliefs. Smokers' beliefs change in concordance with their smoking behavior and functional beliefs tend to play a significant role as compared to risk-minimizing beliefs. Tobacco control messaging and interventions can be framed to target these functional beliefs to facilitate quitting.

Network characteristics of a referral system for patients with hypertension in Western Kenya: results from the Strengthening Referral Networks for Management of Hypertension Across the Health System (STRENGTHS) study.

BACKGROUND: Health system approaches to improve hypertension control require an effective referral network. A national referral strategy exists in Kenya; however, a number of barriers to referral completion persist. This paper is a baseline assessment of a hypertension referral network for a cluster-randomized trial to improve hypertension control and reduce cardiovascular disease risk. METHODS: We used sociometric network analysis to understand the relationships between providers within a network of nine geographic clusters in western Kenya, including primary, secondary, and tertiary care facilities. We conducted a survey which asked providers to nominate individuals and facilities to which they refer patients with controlled and uncontrolled hypertension. Degree centrality measures were used to identify providers in prominent positions, while mixed-effect regression models were used to determine provider characteristics related to the likelihood of receiving referrals. We calculated core-periphery correlation scores (CP) for each cluster (ideal CP score = 1.0). RESULTS: We surveyed 152 providers (physicians, nurses, medical officers, and clinical officers), range 10-36 per cluster. Median number of hypertensive patients seen per month was 40 (range 1-600). While 97% of providers reported referring patients up to a more specialized health facility, only 55% reported referring down to lower level facilities. Individuals were more likely to receive a referral if they had higher level of training, worked at a higher level facility, were male, or had more job experience. CP scores for provider networks range from 0.335 to 0.693, while the CP scores for the facility networks range from 0.707 to 0.949. CONCLUSIONS: This analysis highlights several points of weakness in this referral network including cluster variability, poor provider linkages, and the lack of down referrals. Facility networks were stronger than provider networks. These shortcomings represent opportunities to focus interventions to improve referral networks for hypertension. TRIAL REGISTRATION: Trial Registered on ClinicalTrials.gov NCT03543787 , June 1, 2018.

Strengthening Referral Networks for Management of Hypertension Across the Health System (STRENGTHS) in western Kenya: a study protocol of a cluster randomized trial.

BACKGROUND: Hypertension is a major risk factor for cardiovascular disease (CVD), yet treatment and control rates for hypertension are very low in low- and middle-income countries (LMICs). Lack of effective referral networks between different levels of the health system is one factor that threatens the ability to achieve adequate blood pressure control and prevent CVD-related morbidity. Health information technology and peer support are two strategies that have improved care coordination and clinical outcomes for other disease entities in other settings; however, their effectiveness and cost-effectiveness in strengthening referral networks to improve blood pressure control and reduce CVD risk in low-resource settings are unknown. METHODS/DESIGN: We will use the PRECEDE-PROCEED framework to conduct transdisciplinary implementation research, focused on strengthening referral networks for hypertension in western Kenya. We will conduct a baseline needs and contextual assessment using a mixed-methods approach, in order to inform a participatory, community-based design process to fully develop a contextually and culturally appropriate intervention model that combines health information technology and peer support. Subsequently, we will conduct a two-arm cluster randomized trial comparing 1) usual care for referrals vs 2) referral networks strengthened with our intervention. The primary outcome will be one-year change in systolic blood pressure. The key secondary clinical outcome will be CVD risk reduction, and the key secondary implementation outcomes will include referral process metrics such as referral appropriateness and completion rates. We will conduct a mediation analysis to evaluate the influence of changes in referral network characteristics on intervention outcomes, a moderation analysis to evaluate the influence of baseline referral network characteristics on the effectiveness of the intervention, as well as a process evaluation using the Saunders framework. Finally, we will analyze the incremental cost-effectiveness of the intervention relative to usual care, in terms of costs per unit decrease in systolic blood pressure, per percentage change in CVD risk score, and per disability-adjusted life year saved. DISCUSSION: This study will provide evidence for the implementation of innovative strategies for strengthening referral networks to improve hypertension control in LMICs. If effective, it has the potential to be a scalable model for health systems strengthening in other low-resource settings worldwide. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03543787 . Registered on 29 June 2018.

Strategies for Effective Stakeholder Engagement in Strengthening Referral Networks for Management of Hypertension Across Health Systems in Kenya.

BACKGROUND: Ineffective referral networks in low- and middle-income countries hinders access to evidence-based therapies by hypertensive patients, leading to high cardiovascular mortality and morbidity. The STRENGTHS (Strengthening Referral Networks for Management of Hypertension Across Health Systems) study evaluates strategies to improve referral processes utilizing the International Association of Public Participation framework to engage stakeholders. OBJECTIVES: This study sought to identify and engage key stakeholders involved in referral of patients in the Ministry of Health, western Kenya. METHODS: Key stakeholders involved in policy formulation, provision, or consumption of public health care service were mapped out and contacted by phone, letters, and emissaries to schedule meetings, explain research objectives, and obtain feedback. RESULTS: Key stakeholders identified were the Ministry of Health, the Academic Model Providing Access to Healthcare, health professionals, communities and their leadership, and patients. Engaging them resulted in permission to contact research in their areas of jurisdiction and enabled collaboration in updating care protocols with emphasis on timely and appropriate referrals. CONCLUSIONS: Early stakeholder identification and engagement using the International Association of Public Participation model eased explanation of research objectives, building consensus, and shaping the interventions to improve the referral process.

Network influences on policy implementation: Evidence from a global health treaty.

This paper examines whether country implementation of a public health treaty is influenced by the implementation behaviors of other countries to which they have network ties. We examine implementation of the Framework Convention on Tobacco Control (FCTC) adopted by the World Health Organization in 2003 and ratified by approximately 94% of countries as of 2016. We constructed five networks: (1) geographic distance, (2) general trade, (3) tobacco trade, (4) GLOBALink referrals, and (5) GLOBALink co-subscriptions. Network exposure terms were constructed from these networks based on the implementation scores for six articles of the FCTC treaty. We estimate effects using a lagged Type 1 Tobit model. Results show that network effects were significant: (a) across all networks for article 6 (pricing and taxation), (b) distance, general trade, GL referrals, and GL co-subscriptions for article 8 (second hand smoke), (c) distance, general trade, and GL co-subscriptions for article 11 (packaging and labeling), and (d) distance and GL co-subscription for article 13 (promotion and advertising), (e) tobacco trade and GL co-subscriptions for article 14 (cessation). These results indicate that diffusion effects were more prevalent for pricing and taxation as well as restrictions on smoking in public places and packaging and labeling. These results suggest that network influences are possible in domains that are amenable to control by national governments but unlikely to occur in domains established by existing regulatory systems. Implications for future studies of policy implementation are discussed.

Bridging Income Generation with Group Integrated Care for cardiovascular risk reduction: Rationale and design of the BIGPIC study.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of mortality worldwide, with >80% of CVD deaths occurring in low and middle income countries (LMICs). Diabetes mellitus and pre-diabetes are risk factors for CVD, and CVD is the major cause of morbidity and mortality among individuals with DM. There is a critical period now during which reducing CVD risk among individuals with diabetes and pre-diabetes may have a major impact. Cost-effective, culturally appropriate, and context-specific approaches are required. Two promising strategies to improve health outcomes are group medical visits and microfinance. METHODS/DESIGN: This study tests whether group medical visits integrated into microfinance groups are effective and cost-effective in reducing CVD risk among individuals with diabetes or at increased risk for diabetes in western Kenya. An initial phase of qualitative inquiry will assess contextual factors, facilitators, and barriers that may impact integration of group medical visits and microfinance for CVD risk reduction. Subsequently, we will conduct a four-arm cluster randomized trial comparing: (1) usual clinical care, (2) usual clinical care plus microfinance groups only, (3) group medical visits only, and (4) group medical visits integrated into microfinance groups. The primary outcome measure will be 1-year change in systolic blood pressure, and a key secondary outcome measure is 1-year change in overall CVD risk as measured by the QRISK2 score. We will conduct mediation analysis to evaluate the influence of changes in social network characteristics on intervention outcomes, as well as moderation analysis to evaluate the influence of baseline social network characteristics on effectiveness of the interventions. Cost-effectiveness analysis will be conducted in terms of cost per unit change in systolic blood pressure, percent change in CVD risk score, and per disability-adjusted life year saved. DISCUSSION: This study will provide evidence regarding effectiveness and cost-effectiveness of interventions to reduce CVD risk. We aim to produce generalizable methods and results that can provide a model for adoption in low-resource settings worldwide.

Diffusion of innovations theory applied to global tobacco control treaty ratification.

This study applies diffusion of innovations theory to understand network influences on country ratification of an international health treaty, the Framework Convention for Tobacco Control (FCTC). From 2003 to 2014 approximately 90% of United Nations member countries ratified the FCTC. We hypothesized that communication between tobacco control advocates on GLOBALink, a 7000-member online communication forum in existence from 1992 to 2012, would be associated with the timing of treaty ratification. We further hypothesized dynamic network influences such that external influence decreased over time, internal influence increased over time, and the role of opinion leader countries varied over time. In addition we develop two concepts: Susceptibility and influence that uncover the micro-level dynamics of network influence. Statistical analyses lend support to the influence of co-subscriptions on GLOBALink providing a conduit for inter-country influences on treaty ratification and some support for the dynamic hypotheses. Analyses of susceptibility and infection indicated particularly influential countries. These results have implications for the study of policy diffusion as well as dynamic models of behavior change.

Social network analysis for program implementation.

This paper introduces the use of social network analysis theory and tools for implementation research. The social network perspective is useful for understanding, monitoring, influencing, or evaluating the implementation process when programs, policies, practices, or principles are designed and scaled up or adapted to different settings. We briefly describe common barriers to implementation success and relate them to the social networks of implementation stakeholders. We introduce a few simple measures commonly used in social network analysis and discuss how these measures can be used in program implementation. Using the four stage model of program implementation (exploration, adoption, implementation, and sustainment) proposed by Aarons and colleagues [1] and our experience in developing multi-sector partnerships involving community leaders, organizations, practitioners, and researchers, we show how network measures can be used at each stage to monitor, intervene, and improve the implementation process. Examples are provided to illustrate these concepts. We conclude with expected benefits and challenges associated with this approach.

Transforming mental health services: a participatory mixed methods study to promote and evaluate the implementation of recovery-oriented services.

BACKGROUND: Since 2007, the Mental Health Commission of Canada has worked collaboratively across all provinces to publish a framework and strategy for recovery and well-being. This federal document is now mandated as policy for implementation between 2012 and 2017. The proposed strategies have been written into provincial health plans, hospital accreditation standards, and annual objectives of psychiatric departments and community organizations. The core premise is: to empower persons with mental illness and their families to become participants in designing their own care, while meeting the needs of a diverse Canadian population. However, recovery principles do not come with an implementation guide to fit the variability of different local contexts. How can policy recommendations and accreditation standards be effectively tailored to support a diversity of stakeholder values? To our knowledge, there is little evidence indicating the most effective manner to accelerate the uptake of recovery-oriented services among providers in a given/particular mental health treatment setting. METHODS/DESIGN: This three-year Canadian Institute of Health Research Partnership in Health System Improvement and The Rx&D Health Research Foundation (HRF) Fostering Canadian Innovation in Research study (2013 to 2017) proposed participatory approaches to implementing recovery principles in a Department of Psychiatry serving a highly diverse Canadian and immigrant population. This project will be conducted in overlapping and recursive phases: I) Conduct formative research to (a) measure the current knowledge and attitudes toward recovery and recovery-oriented practices among service providers, while concurrently (b) exploring the experiential knowledge of recovery service-users and family members; II) Collaborate with service-users and the network-identified opinion leaders among providers to tailor Recovery-in-Action Initiatives to fit the needs and resources of a Department of Psychiatry; and III) Conduct a systematic theory-based evaluation of changes in attitudes and practices within the service-user/service-provider partnership group relative to the overall provider network of the department and identify the barriers and supports within the local context. DISCUSSION: Our anticipated outcome is a participatory toolkit to tailor recovery-oriented services, which will be disseminated to the Mental Health Commission of Canada and Accreditation Canada at the federal level, agencies at the provincial levels, and local knowledge end-users.

A comparison of peer influence measures as predictors of smoking among predominately hispanic/latino high school adolescents.

PURPOSE: Consistent evidence has shown that one of the most significant influences on adolescent smoking is peer influence. There is considerable variation, however, in how peer influence is measured. This study constructs social network influence and selection variables from egocentric and sociometric data to compare their associations with smoking, with considerations of perceived smoking norms and adolescent popularity. METHODS: Longitudinal data were collected in the 9th and 10th grades in October 2006 and 2007 from predominantly Hispanic/Latino adolescents in seven Southern California schools; among these adolescents, 1,950 completed surveys at both waves. Both cross-sectional (separately for 9th and 10th graders) and longitudinal models were estimated. RESULTS: An egocentric measure of perceived friend smoking was strongly and consistently associated with individual smoking (adjusted odds ratio [AOR] ≈ 1.80, p < .001), whereas its sociometric counterpart of friend self-report smoking was only associated with smoking in the 9th-grade cross-sectional models (e.g., AOR = 1.56, p < .001) and rarely in longitudinal models. Popularity, measured by proportion of nominations received by class size, was associated with smoking and becoming a smoker (AOR = 1.67, p < .001), whereas perceived norms were not, in longitudinal models. Friend selection was also associated with becoming a smoker (AOR = 1.32, p = .05). CONCLUSIONS: This study illustrates the utility of egocentric data for understanding peer influence and underscores the importance of perceptions and popularity as mechanisms that influence adolescent smoking.

A network assessment of community-based participatory research: linking communities and universities to reduce cancer disparities.

OBJECTIVES: We sought to determine whether a community-based initiative designed to reduce cancer disparities among Pacific Islanders in Southern California increased communications between community-based organizations and university researchers. METHODS: We conducted network analysis among 11 community-based organizations (CBOs) and 5 universities by interviewing 91 and 56 members of these organizations, respectively, at 2 points in time. We estimated random effects probit regression and stochastic actor-oriented network dynamic models. RESULTS: We found that, during the 2-year study period, CBOs increased their connectedness with one another (b= 0.44; P < .05) and to the universities (b = 0.46; P < .05), but that university researchers did not increase their connectedness to each other or to CBOs. CONCLUSIONS: Cancer awareness, cancer education, and access to cancer services are low among Pacific Island groups, and this study provides an initial attempt to reduce these disparities. Community-based initiatives can strengthen a CBO network, creating the potential for increased community-informed cancer research and improved community access to cancer research resources.

Global tobacco control diffusion: the case of the framework convention on tobacco control.

OBJECTIVES: We analyzed demographic and social network variables associated with the timing of ratification of the Framework Convention on Tobacco Control (FCTC). METHODS: We compiled a 2-mode data set that recorded country participation in FCTC negotiations, as well as the number of individuals per country per year who joined an online tobacco control network. We used logistic regression analysis of these 2 data sets along with geographic location to determine whether exposure to prior FCTC adoptions was associated with a country's likelihood of adoption. RESULTS: In the logistic regression analysis, higher income and more nongovernmental organizations (NGOs) involved in the Framework Convention Alliance (a network dedicated to the FCTC) were associated with being among the earliest adopters (for income, adjusted odds ratio [AOR] = 2.41; 95% confidence interval [CI] = 1.55; for NGOs, AOR = 1.66; 95% CI = 1.26, 2.17) or among early adopters (for income, AOR = 1.42; 95% CI = 1.09, 1.84; for NGOs, AOR = 1.23; 95% CI = 1.03, 1.45). Network exposure and event history analysis showed that in addition to income, the likelihood of adoption increased with increasing affiliation exposure to FCTC adopters through GLOBALink (an online network facilitating communication between tobacco control advocates). CONCLUSIONS: Public health programs should include a plan for creating opportunities for network interaction; otherwise, adoption and diffusion will be delayed and the investments in public health policy greatly diminished.

Collaboration and competition in a children's health initiative coalition: a network analysis.

Activating communities to achieve public health change and initiate policy reform usually requires collective action from many entities. This case study analyzes inter-organizational networks among members of a coalition created to expand health insurance coverage to uninsured children in a large metropolitan area. Six networks were measured: collaboration, competition, formal agreements, receive funding from, send funding to, and greater communication. The response rate was 65.8% (50 of the 76 active members). Positive network questions such as "who do you collaborate with" elicited many network choices whereas negative ones such as "who do you compete with" elicited few. The collaboration network had a core-periphery structure and analysis showed that a large network can be reduced to a small set of core organizations one-sixth the size of the whole. Centrality (out- and in-degree) was associated with perceived organizational function and perceived barriers to success. For example, organizations that received many choices as collaboration partners were more likely to perceive the coalition functioned well than those who received few choices. The study suggests that perceptions of organizational performance are associated with position in the network, central members are more likely to perceive the organization performs well than those on the periphery.

Between tradition and change: condom use with primary sexual partners among Mexican migrants.

The frequency of male Mexico-US migration has been associated with increased HIV risk for sexual partners awaiting their return in Mexico. This study examined the association between sexual partner characteristics and condom use among a sample of 354 male migrants from two Mexican municipalities. Migrants were interviewed about their past year's sex practices. Results indicated that migrants were more likely to use condoms with their non-spousal partners, partners with less education than the migrant, and partners with higher employment status. Condom use was greater among younger migrants and residents of the more densely populated municipality. Findings suggest the coexistence of a traditional cultural orientation that does not support condom use and another one that does provided the sex partner is formally employed. Prevention programs must strengthen the structural conditions fostering greater equality between the sexes and adapt their approaches for different population density, age and partner types.

Network analysis of an organizational collaboration for Pacific Islander cancer control.

Community-based participatory research (CPBR) represents a growing research approach for addressing health disparities disfavoring members of racial/ethnic minorities and other underserved populations in the U.S. While such endeavors are often guided by explicit principles regarding the relationships between communities and universities, few studies have reported on the development or strength of such relationships. This paper describes the methods and preliminary results of a cross-sectional analysis of the ties between community and university organizations in a CBPR network to address cancer disparities between Pacific Islanders in Southern California and the general population. These analyses afford a means of representing the collaborative relationships and may enhance tracking improvements in CBPR links for cancer education, research, and training. Such tracking will help concerned parties understand how academic and community groups collaborate and coordinate their efforts to reach shared and overlapping goals.

Peer acceleration: effects of a social network tailored substance abuse prevention program among high-risk adolescents.

OBJECTIVE: To test whether a social network tailored substance abuse prevention program can reduce substance use among high-risk adolescents without creating deviancy training (iatrogenic effects). METHODS: A classroom randomized controlled trial comparing control classes with those receiving an evidence-based substance use prevention program [Towards No Drug Abuse (TND)] and TND Network, a peer-led interactive version of TND. Students (n = 541, mean age 16.3 years) in 75 classes from 14 alternative high schools completed surveys before and approximately 1 year after curriculum delivery. Past-month use of tobacco, alcohol, marijuana and cocaine were assessed. RESULTS: Overall, TND Network was effective in reducing substance use. However, the program effect interacted with peer influence and was effective mainly for students who had peer networks that did not use substances. Students with classroom friends who use substances were more likely to increase their use. CONCLUSIONS: A peer-led interactive substance abuse prevention program can accelerate peer influences. For students with a peer environment that supports non-use, the program was effective and reduced substance use. For students with a peer environment that supports substance use, an interactive program may have deleterious effects.

Promoting breastfeeding in Bolivia: do social networks add to the predictive value of traditional socioeconomic characteristics?

This study tested whether the prediction of health-related knowledge (correct breastfeeding practices in this case) could be improved by including information about the composition of an individual's personal network above and beyond that predicted by his/her socioeconomic or demographic characteristics. Few studies have tested the predictive value of social networks, especially for population-based studies, despite an increased use of social networks in the past few years in several fields of health research, especially in research relating to prevention of HIV/AIDS and design of HIV/AIDS programmes. Promotion of breastfeeding practices that enhance child survival is important in Bolivia because of high infant morbidity and mortality in the country. Data on a cross-sectional urban probability sample of 2,354 women and men aged 15-49 years were collected from seven urban areas in Bolivia. Model building and the log likelihood ratio criteria were used for assessing the significance of variables in a logistic model. Results showed that the network variables added significantly (p < 0.05 for knowledge of breastfeeding only with no other liquids and for knowledge of breastfeeding only with no solids p < 0.01) to the predictive power of the socioeconomic variables. These results may also hold for other health research areas, increasingly using social network analysis, such as that of HIV/AIDS.

Improving preventive health services training in chiropractic colleges: a pilot impact evaluation of the introduction of a model public health curriculum.

OBJECTIVE: To investigate the impact of the dissemination of the model public curriculum at one US chiropractic college on chiropractic interns during their outpatient clinical internship. METHODS: A retrospective pilot study was performed to evaluate the frequency of 9 patient clinical preventive health recommendations made by interns during their clinical training. The frequency of recommendations by interns completing their public health coursework after dissemination of the model curriculum was compared with those completing their coursework during the period immediately proceeding dissemination. A standardized data abstraction tool was developed to collect data from clinic charts that established a patient's need for any one of 9 preventive health services. RESULTS: Of the 408 charts examined (204 from each group), there were only 4 documented instances (1%) of recommendations for any of the 9 preventive health service categories. Two recommendations occurred in the precurriculum change period. CONCLUSION: The results of this pilot study indicate that there has been no observable impact on intern behaviors toward educating patients in preventive health services since the dissemination of the model public health curriculum at one of the chiropractic colleges in the United States. The impact of this reform in public health education may have been limited by its minimal focus on clinical preventive services and by a focus on didactic rather than a clinically relevant learning exposure.