Implementing FCTC Article 17 Through Participatory Research With Bidi Workers in Tamil Nadu, India.

INTRODUCTION: The exploitation, poor conditions, and precarity in the bidi (hand-rolled leaf cigarette) industry in India make it ripe for the application of the FCTC's Article 17, "Provision of support for economically viable alternative activities". "Bottom-up", participatory approaches give scope to explore bidi rollers' own circumstances, experiences, and aspirations. METHODS: A team of six community health volunteers using a participatory research orientation developed a questionnaire-based semi-structured interview tool. Forty-six bidi rolling women were interviewed by pairs of volunteers in two northern Tamil Nadu cities. Two follow-up focus groups were also held. A panel of 11 bidi rollers attended a workshop at which the findings from the interviews and focus groups were presented, further significant points were made and possible alternatives to bidi rolling were discussed. RESULTS: Bidi workers are aware of the adverse impact of their occupation on them and their families, as well as the major risks posed by the product itself for the health of consumers. However, they need alternative livelihoods that offer equivalent remuneration, convenience, and (in some cases) dignity. Alternative livelihoods, and campaigns for better rights for bidi workers while they remain in the industry, serve to undercut industry arguments against tobacco control. Responses need to be diverse and specific to local situations, i.e. "bottom-up" as much as "top-down", which can make the issue of scaling up problematic. CONCLUSION: Participatory approaches involving bidi workers themselves in discussions about their circumstances and aspirations have opened up new possibilities for alternative livelihoods to tobacco. IMPLICATIONS: Progress with the FCTC's Article 17 has generally been slow and has focussed on tobacco cultivation rather than later stages in the production process. The bidi industry in India is ripe for the application of an alternative livelihoods approach. This study is one of the first to use participatory methods to investigate the circumstances, experiences, and aspirations of bidi workers themselves.

Incidence and risk factors for clozapine-induced myocarditis and cardiomyopathy at a regional mental health service in Australia.

OBJECTIVE: To determine the incidence of clozapine-induced myocarditis and cardiomyopathy and identify risk factors. METHOD: A cohort of 129 patients initiated on clozapine at Toowoomba Mental Health Service from year 2000 until 2011 was examined to evaluate cases of myocarditis and cardiomyopathy. Risk factors were analysed using multivariable logistic regression. RESULTS: The incidence of clozapine-induced myocarditis and cardiomyopathy was 3.88% and 4.65% (or 2.26 per 100 patient years), respectively. A significant association was identified between clozapine-induced myocarditis and SSRI use (p = 0.043). Subclinical cardiomyopathy was identified in the absence of symptoms in the majority of cases. CONCLUSIONS: These results illustrate a high incidence of clozapine-induced myocarditis as well as cardiomyopathy, reinforcing the need for a standardised, mandatory monitoring scheme. Concomitant SSRI use as one such potential predictor merits further study.

Investing in communities: evaluating the added value of community mobilization on HIV prevention outcomes among FSWs in India.

Community mobilization often requires greater time and resource investments than typical interventions, yet few evaluations exist to justify these investments. We evaluated the added benefit of community mobilization on HIV prevention outcomes among female sex workers (FSWs) using a composite measure of volunteer participation in program committees by FSWs. After adjusting for treatment propensity, we used multilevel structural equation modeling (MSEM) to test our program theory. We hypothesized that stronger community mobilization would be associated with increased levels of consistent condom use and with increased levels of perceived fairness, mediated by psychosocial processes. Community mobilization had an indirect effect on consistent condom use mediated through social cohesion and an indirect effect on perceived fairness mediated by collective efficacy. Our results suggest higher levels of community mobilization help improve condom use and reduce perceived discrimination beyond the effects of the core HIV intervention program. We recommend further testing of this model.

Monitoring community mobilisation and organisational capacity among high-risk groups in a large-scale HIV prevention programme in India: selected findings using a Community Ownership and Preparedness Index.

BACKGROUND: In a participatory approach to health and development interventions, defining and measuring community mobilisation is important, but it is challenging to do this effectively, especially at scale. METHODS: A cross-sectional, participatory monitoring tool was administered in 2008-2009 and 2009-2010 across a representative sample of 25 community-based groups (CBGs) formed under the Avahan India AIDS Initiative, to assess their progress in mobilisation, and to inform efforts to strengthen the groups and make them sustainable. The survey used a weighted index to capture both qualitative and quantitative data in numeric form. The index permitted broad, as well as highly detailed, analysis of community mobilisation, relevant at the level of individual groups, as well as state-wide and across the whole programme. RESULTS: The survey demonstrated that leadership and programme management were the strongest areas among the CBGs, confirming the programme's investment in these areas. Discussion of the Round 1 results led to efforts to strengthen governance and democratic decision making in the groups, and progress was reflected in the Round 2 survey results. CBG engagement with state authorities to gain rights and entitlements and securing the long-term financial stability of groups remain a challenge. CONCLUSION: The survey has proven useful for informing the managers of programmes about what is happening on the ground, and it has opened spaces for discussion within community groups about the nature of leadership, decision making and their goals, which is leading to accelerated progress. The tool provided useful data to manage community mobilisation in Avahan.

Navigating the swampy lowland: a framework for evaluating the effect of community mobilisation in female sex workers in Avahan, the India AIDS Initiative.

BACKGROUND: Few models of how community mobilisation works have been elaborated in the scientific literature, and evaluation of the impact of these programmes on HIV and other health outcomes is extremely limited. Avahan, the India AIDS Initiative, has been implementing community mobilisation as part of its prevention programming with groups of high-risk individuals across six states since 2005. PURPOSE: To articulate a programme theory and evaluation framework for evaluation of Avahan's approach to community mobilisation among female sex workers in four southern states in India. METHODS: The authors use a goal-based evaluation approach to describe the programme goals and an underlying programme theory that specifies how the programme is expected to work. Using multilevel structural equation modelling with propensity score matching, the evaluation will compare what is observed in the data with the predicted relationships specified by the model. RESULTS: The Avahan model of community mobilisation posits that meaningful participation in high-risk group intervention, structural intervention and organisational development activities leads to identification, collectivisation and ownership, which in turn leads to improved programme outcomes. Strong community groups and an enabling environment reinforce social norm and behaviour change outcomes and lead to sustained impact. DISCUSSION: Specifying an explicit programme theory can aid in the evaluation of complex interventions, especially when the evaluation design is observational. In addition to articulating Avahan's community mobilisation approach in a model that can be tested, we recommend some specific measures and methods that could be used to improve evaluation efforts in the future.

Design of a Community Ownership and Preparedness Index: using data to inform the capacity development of community-based groups.

BACKGROUND: Community mobilisation is an important component of a participatory approach to health and development interventions. However, it is challenging to define, measure and assess community participation and ownership of a programme, especially at scale. METHODS: An iterative cross-sectional survey was designed for implementation across a representative sample of community-based groups, using a weighted index that captured both qualitative and quantitative data in a standardised form. These data were aggregated at the level of individual groups, as well as state-wide or across the whole programme. Community participation in the survey is a primary feature of the methodology and was integral to the process of designing the index and administering the survey. RESULTS: The survey provided programme management and communities with objective tools for monitoring community mobilisation across a large-scale and complex intervention covering 32 districts in India. The implementation of the survey engaged communities in an open discussion of their goals and capabilities and helped them to challenge the power dynamics between themselves and other stakeholders. CONCLUSIONS: It is possible to translate the theoretical premises of participatory development into a tool that both measures and fosters meaningful participation. The active participation of community members in the collection and analysis of data on their mobilisation suggests that monitoring of participation can be undertaken to inform a scaled-up programme and can be a useful intervention in its own right.

Nutrient composition of cultivated stevia leaves and the influence of polyphenols and plant pigments on sensory and antioxidant properties of leaf extracts.

Stevia rebaudiana is an introduced crop in India. The leaf and its extract although sweet have a bitter after taste that precludes commercial acceptability. The composition of the leaf reflected a high nutritive value and polyphenol concentration averaging 4.15% by weight of dried leaf. Variably processed extracts enriched with polyphenols, pigments and a mixture of both were evaluated for sensory attributes by a semi trained panel when added to cofee and lime juice. Presence of polyphenols influenced the acceptability of the sweeteners marginally, while chlorophyll was found unacceptable in any of the extracts. The antioxidant activity of the extracts was synergistic when it was mixed with coffee and lime juice. Complete purification of stevia leaf extracts to obtain pure glycosides is not necessary for it to become a commercially acceptable sweetener.