Feasibility of tobacco cessation intervention at non-communicable diseases clinics: A qualitative study from a North Indian State.

BACKGROUND: One of the 'best buys' for preventing Non-Communicable Diseases (NCDs) is to reduce tobacco use. The synergy scenario of NCDs with tobacco use necessitates converging interventions under two vertical programs to address co-morbidities and other collateral benefits. The current study was undertaken with an objective to ascertain the feasibility of integrating a tobacco cessation package into NCD clinics, especially from the perspective of healthcare providers, along with potential drivers and barriers impacting its implementation. METHODS: A disease-specific, patient-centric, and culturally-sensitive tobacco cessation intervention package was developed (published elsewhere) for the Health Care Providers (HCPs) and patients attending the NCD clinics of Punjab, India. The HCPs received training on how to deliver the package. Between January to April 2020, we conducted a total of 45 in-depth interviews [medical officers (n = 12), counselors (n = 13), program officers (n = 10), and nurses (n = 10)] within the trained cohort across various districts of Punjab until no new information emerged. The interview data wereanalyzed deductively based on six focus areas concerning feasibility studies (acceptability, demand, adaptation, practicality, implementation, and integration) using the 7- step Framework method of qualitative analysis and put under preset themes. RESULTS: The respondent's Mean ± SD age was 39.2± 9.2 years, and years of service in the current position were 5.5 ± 3.7 years. The study participants emphasized the role of HCPs in cessation support (theme: appropriateness and suitability), use of motivational interviewing, 5A's & 5R's protocol learned during the training & tailoring the cessation advice (theme: actual use of intervention activities); preferred face-to-face counseling using regional images, metaphors, language, case vignettes in package (theme: the extent of delivery to intended participants). Besides, they also highlighted various roadblocks and facilitators during implementation at four levels, viz. HCP, facility, patient, and community (theme: barriers and favorable factors); suggested various adaptations to keep the HCPs motivated along with the development of integrated standard operating procedures (SOPs), digitalization of the intervention package, involvement of grassroots level workers (theme: modifications required); the establishment of an inter-programmatic referral system, and a strong politico-administrative commitment (theme: integrational perspectives). CONCLUSION: The findings suggest that implementing a tobacco cessation intervention package through the existing NCD clinics is feasible, and it forges synergies to obtain mutual benefits. Therefore, an integrated approach at the primary & secondary levels needs to be adopted to strengthen the existing healthcare systems.

Awareness of electronic cigarettes in India: Findings from the 2016-2017 Global Adult Tobacco Survey (GATS).

INTRODUCTION: Electronic nicotine delivery systems (ENDS) have recently emerged as a public health threat globally. Despite the low proportion of e-cigarette users (1.22%) reported in the Global Adult Tobacco Survey-2, the Government of India enacted the Prohibition of E-cigarettes Act 2019 (PECA), prohibiting all forms of ENDS/ENNDS. The current analysis presents nationally representative findings on the level of awareness of e-cigarettes in India and its correlates and characteristics of those aware of e-cigarettes. METHODS: The current secondary analysis from GATS-2 among adults aged ≥15 years from all states and Union Territories of India used a standard protocol for data collection and management. A multi-stage cluster sampling design was used. The respondents who were aware of e-cigarettes were included (n=2524). Binomial logistic regression analysis was conducted, and adjusted odds ratios (AORs) with 95% CI, were calculated to measure the associations between independent and dependent variables. RESULTS: Only 3.4% of the respondents were aware (either heard or seen) of e-cigarettes and their awareness was found significantly higher among males (AOR=2.07; 95% CI: 1.90-2.24), urban population (AOR=2.83; 95% CI: 2.61-3.07), and higher education (AOR=0.41; 95% CI: 0.38-0.45). CONCLUSIONS: Public awareness campaigns about the harms of e-cigarettes and the law (PECA) need to be rolled out in urban and rural areas. Capacity-building exercises of implementers and enforcers at the grassroots level could also support communicating the harms to hard-to-reach groups. Further, regular compliance monitoring of the legislation and prosecution of violators would facilitate its effective implementation at the national and sub-national levels.

Prevalence of hypertension and determinants of treatment-seeking behaviour among adolescents and young adults in India: an analysis of NFHS-4.

BACKGROUND: Previous evidences have reported that almost three-fourth of young hypertensives are not seeking care for their condition leading to severe complications. This study was conducted to assess the determinants of treatment-seeking behaviour among the young hypertensives in India. METHODS: The National Family Health Survey-4 data were analysed. Sampling weights and clustering was accounted using svyset command. Screening, awareness, prevalence and control status were reported with 95% confidence interval (CI). Poisson regression was done to identify the determinants of treatment-seeking behaviour. RESULTS: In total, 13.8% of younger adults had hypertension, 51.1% were aware of their status and 19.5% sought treatment. Participants in 15-19 years (adjusted Prevalence Ratio (aPR) = 0.70) and 20-29 years (aPR = 0.63), male gender (aPR = 0.84), Muslim religion (aPR = 1.14), urban region (aPR = 0.87), secondary (aPR = 0.88) and higher education (aPR = 0.86), residing in Northern (aPR = 0.79), Central (aPR = 0.76), Southern region (aPR = 0.65), preferring home treatment, medical shop or any other care (aPR = 0.63) were significant determinants of treatment-seeking behaviour. CONCLUSION: More than 1 in 10 younger adults in India have hypertension and only half of them were aware of their status and one-fifth sought treatment. Adolescents, males, Hindus, urban population, higher education and residing in Northern, Central and Southern region had poor treatment-seeking behaviour.

Urban-rural disparities in blood pressure and lifestyle risk factors of hypertension among Indian individuals.

Objectives: This study aims to assess the urban-rural difference in prevalence of hypertension (HT) and to explore the disparities in lifestyle risk factors of HT among urban and rural individuals aged 15-49 years in India. Study Design: The cross-sectional data collected as a part of the fourth round of National Family Health Survey (NFHS-4) was analysed in this observational study. NFHS-4 was conducted between January 2015 and December 2016 amongst men aged 15-54 years and women aged 15-49 years. In order to maintain uniformity, age group of 15-49 years was considered. Descriptive analyses were performed for sociodemographic and lifestyle factors. Binary logistic regression was conducted to assess the predictors of HT in men and women in urban and rural settings. The presence of HT was considered as the outcome variable. Results: The overall age adjusted prevalence of HT was 17.2% and was greater in urban (18.3%) than in rural population (15.5%). The age adjusted prevalence was also higher in males (18.2%) as compared to females (16.1%). Age and wealth were associated with HT in both urban and rural population. Education and dietary habits played a role in all except rural men. Alcohol consumption, diabetic status and marital status were significantly associated with HT in both urban and rural women. Occupation was associated with HT only in urban women. Conclusions: The study has shown higher HT prevalence in urban areas despite higher prevalence of lifestyle risk factors in rural settings. This calls for more robust screening and health education in the entire population, especially in rural areas.

Establishing nomogram of blood pressure for late adolescents in India: Secondary analysis of NFHS-4 data.

Background: Hypertension among adolescents is a public health problem, which is going to become more severe given the current obesity epidemic. There is a scarcity of information on the reference range value for blood pressure (BP) cut-off for adolescents. Aim: We aimed to establish BP distribution in adolescents aged 15-19 years by using the nationally representative National Family Health Survey-4 (NFHS-4) data. Materials and Methods: We analyzed the data of 15,936 boys and 1,04,132 girls aged 15-19 years in the NFHS-4 survey. We took the mean of systolic and diastolic BPs. Height for age z scores for each individual was calculated using the WHO Anthro plus. The sampling weight was taken as provided by the demographic and health surveys (DHS) website. Nomograms of systolic and diastolic BPs were made by calculating their 50th, 90th, and 95th percentiles for each age (in months), gender, and height percentile for age categories. Results: Both systolic and diastolic BPs increased with age and height centiles. The BP was higher in boys than girls. The average annual increase in systolic and diastolic BPs was 2.52 and 1.20 mmHg in boys and 0.50 and 0.46 mmHg in girls, respectively, when adjusted for height centiles. Conclusion: This study provides a BP nomogram that can be generalized to all the Indian population. Research is required for the diagnostic performance of this nomogram for the diagnosis of adolescent hypertension.

Development of integrated model of communication for implementing media strategy to prevent hypertension in a northern state of India.

OBJECTIVE: Media plays a major role in inculcating positive changes or averting negative changes in health-related behaviors across populations. Although various mass media interventions have proven their effectiveness in changing individuals' behavior for various diseases and risk factors, current literature is limited regarding a conceptual framework/model for the prevention of hypertension and cardiovascular diseases. The present study describes the process of development and implementation of a comprehensive and need-based media strategy with an aim to generate politico-administrative support for strengthening hypertension services in the state of Punjab, India. METHODS: The preparation of theoretical framework underwent two stages, that is, item generation and item reduction. The item generation involved extensive literature search, development of consensus among experts using Delphi technique and its validation. The item reduction involved the selection of models among existing communication and health promotion models, placement of items in the selected models and development of final conceptual framework model. RESULTS: Based upon the review and expert's consensus, we zeroed in on three models of communication - communication campaign model, paid earned social owned model, and staircase model - in order to come up with the framework requisite for a systematic media strategy. The model focused upon context-specific messages involving both traditional and modern means and tools of communication. This model (conceptual framework) was the product of intense literature review followed by opinion of the experts from various disciplines such as medical professionals, public health specialists, communication experts, social scientists, politicians, bureaucrats, state-level representatives, media journalists and hypertensive patients. CONCLUSION: The present model can effectively be used by the program implementers, educators and policy makers in similar settings.

The feasibility and acceptability of various bovine brucellosis control strategies in India.

Bovine brucellosis is a neglected zoonotic disease prevalent in several developing countries including India. It has been successfully controlled in many developed countries by using vaccination in conjunction with extensive surveillance and test-and-cull approaches, but some of these approaches do not suit Indian culture and norms. This study was conducted to investigate the feasibility and social acceptability of various bovine brucellosis control strategies in India. Focus group discussions and key-informant interviews were conducted with veterinarians, para-veterinarians, veterinary academics, farmers and other stakeholders. Vaccination with the Brucella strain 19 vaccine was considered feasible, but the participants were concerned about the risk of self-inoculation, the inability to vaccinate pregnant and male animals, the difficulty to differentiate vaccinated from diseased animals and the challenges of maintaining the vaccine cold chain in India. As expected, the test-and-cull approach was not considered feasible as cattle are considered sacred by Hindus and their slaughter is banned in most states. Although the test-and-segregation approach appears reasonable in theory, it would have low acceptability, if implemented without providing any compensation to farmers. Negligible biosecurity was implemented by farmers: almost no biosecurity procedures were performed for visitors entering a farm, and testing of animals was rarely undertaken before introducing them to a farm. However, the participants considered that improving biosecurity would be more acceptable and feasible than both the test-and-cull and the test-and-segregation approaches. Similarly, inadequate personal protection was used by veterinary personnel for handling parturition, retention of placenta and abortion cases; this was considered as another area of possible improvement. Farmers and veterinarians expressed serious concerns about stray cattle as many of them could potentially be infected with brucellosis, and thus could spread the infection between farms. This study recommends using vaccination and biosecurity along with some ancillary strategies to control brucellosis in India. Information from the study could be used to develop an evidence-based disease control program for the disease in the country.

Using Dairy Value Chains to Identify Production Constraints and Biosecurity Risks.

The dairy industry plays an important role in the economy and food security of India. A study of the dairy value chains was conducted in Punjab, India, to identify production constraints and biosecurity risks. Focus group discussions and key informant interviews were conducted during 2018-2019 with a total of 119 participants comprising veterinarians (41), paraveterinarians (15), veterinary academics (12), dairy farmers (46) and key informants (5). Input and output value chains were created, and potential risk nodes were identified that could facilitate the transmission of pathogens between animals, farms and villages. The majority of the participants were male (93%), middle-aged (68%) or worked in rural areas (75%). Most of the farmers self-cultivated their green fodder (82%), used the wheat straw from their own fields (60%) but purchased commercial feed (63%). Artificial insemination was used by 85% of farmers for cattle, but only 68% for buffaloes. Most of the farmers (76%) reported getting their animals vaccinated against foot-and-mouth disease and hemorrhagic septicemia. Animals were sold and purchased without any health certification and testing in most cases. Adoption of biosecurity measures by farmers and the use of personal protective equipment by veterinary personnel were very low. We recommend conducting epidemiological studies to further characterize the identified risk nodes, training of veterinary practitioners and farmers to ensure adequate biosecurity practices and the appropriate use of personal protective equipment.

Understanding the determinants of happiness through Gallup World Poll.

BACKGROUND: The idea of happiness is as old as civilization, but breakthrough is achieved only in 20th century. Happiness can be broadly segmented into biological and behavioural component. The sufferings from illnesses hamper happiness. Happiness correlates negatively with morbidity, mortality, stress and anxiety in contrast to a positive correlation with motivation, healthy behaviours and longevity. In this article, an attempt has been made to understand the relationship between happiness and its important contributory factors. MATERIAL AND METHODS: The current study used data from the Gallup World Poll available under license CC0. Data analysis was performed using R studio version 1.0.136. Initially, descriptive analysis in the form of mean (standard deviation), violin plot, correlation matrix, and scatter plots were reported. Subsequently, robust regression estimates along with bootstrap standard errors and confidence intervals were used to report inferential statistics. RESULTS: Norway, with a happiness score of 7.537 ranked first followed by Denmark with a score of 7.522. Burundi with a score of 2.905 is at the bottom of ranking for happiness. Freedom (CI; 0.95-2.22) and Family (CI; 0.92 - 1.57) are the strongest predictors of happiness. The trust variable does not have a significant (CI; -0.27 - 1.94) relationship with happiness. CONCLUSIONS: The values and norms in society are changing at a fast pace. Therefore, the measures of happiness require consistent and innovative approaches to measure it.

Evaluation of a women group led health communication program in Haryana, India.

BACKGROUND: Sakshar Mahila Smooh (SMS) program was launched in rural areas of Haryana in India during 2008. A total of 6788 SMSs, each having 5-10 literate women, were equipped to enhance health communication. We carried out process evaluation of this program as an external agency. METHODOLOGY: After a review of program documents, a random sample survey of Auxiliary Nurse Midwives (ANMs), SMS members, and village women was conducted. Out of four divisions of the state, one was randomly chosen, which had five districts. From 330 randomly chosen villages, 283 ANMs, 1164 SMS members, and 1123 village women were interviewed using a semi- structured interview schedule. Program inputs, processes, and outputs were compared in the five districts. Chi square was used for significance test. RESULTS: In the sampled division, out of 2009 villages, 1732 (86%) had functional SMS. In three years, SMS conducted 15036 group meetings, 2795 rallies, 2048 wall writings, and 803 competitions, and 44.5% of allocated budget was utilized. Most ANMs opined that SMSs are better health communicators. SMS members were aware about their roles and responsibilities. Majority of village women reported that SMS carry out useful health education activities. The characteristics of SMS members were similar but program performance was better in districts where health managers were proactive in program planning and monitoring. CONCLUSIONS: SMS Program has communicated health messages to majority of rural population, however, better planning & monitoring can improve program performance.

Is Focus on Prevention Missing in National Health Programs? A Situation Analysis of IEC/BCC/Health Promotion Activities in a District Setting of Punjab and Haryana.

CONTEXT: Health promotion (HP) has been an integral part of all national programs although it has been a low priority in India, which has resulted in a failure to achieve the desired results. SETTINGS AND DESIGN: Situation analysis of information education communication (IEC)/behavior change communication (BCC)/HP activities within the existing national health programs was undertaken in the district of Hoshiarpur in Punjab and the district of Ambala in Haryana during 2013-14. MATERIALS AND METHODS: Facility-based assessments were done by conducting in-depth interviews with stakeholders, program officers, medical officers, health workers, and counselors. Household survey (332 individuals) and exit interview (102 interviews) were conducted to assess the knowledge of the community regarding key risk factors. RESULTS: There was a high vacancy in the mass media division with 40% (2 out of 5) and 89% (8 out of 9) of the sanctioned positions vacant in Hoshiarpur and Ambala, respectively, with low capacity of staff and budget. There was no annual calendar, logbook of activities with poor recording of IEC material received and disseminated. The knowledge of community members regarding key risk factors such as tobacco use, salt intake, blood pressure level, anemia, and tuberculosis was 77.3%, 26.4%, 16.4%, 32.7%, and 91.8%, respectively, in the district of Ambala as compared to 77.5%, 37.5%, 33.3%, 25.8%, and 88.3%, respectively, in the district of Hoshiarpur. The village health and sanitation committee (VHSC) in the district of Hoshiarpur and village level core committee (VLCC) in the district of Ambala were found to be nonfunctional with no Iec/Bcc activities in the covered villages in the last month. Monitoring and supervision of Iec/Bcc activities were poor in both the districts. CONCLUSIONS: Iec/Bcc/HP is a neglected area in national health programs in the selected districts with inadequate budget, human resources with poor implementation, and requires strengthening for better implementation of the national health programs.

Developing and implementing an accreditation system for health promoting schools in Northern India: a cross-sectional study.

BACKGROUND: The "Health Promoting School" (HPS) is a holistic and comprehensive approach to integrating health promotion within the community. At the time of conducting this study, there was no organized accreditation system for HPS in India. We therefore developed an accreditation system for HPSs using support from key stakeholders and implemented this system in HPS in Chandigarh territory, India. METHODS: A desk review was undertaken to review HPS accreditation processes used in other countries. An HPS accreditation manual was drafted after discussions with key stakeholders. Seventeen schools (eight government and nine private) were included in the study. A workshop was held with school principals and teachers and other key stakeholders, during which parameters, domains and an accreditation checklist were discussed and finalized. The process of accreditation of these 17 schools was initiated in 2011 according to the accreditation manual. HPSs were encouraged to undertake activities to increase their accreditation grade and were reassessed in 2013 to monitor progress. Each school was graded on the basis of the accreditation scores obtained. RESULTS: The accreditation manual featured an accreditation checklist, with parameters, scores and domains. It categorized accreditation into four levels: bronze, silver, gold and platinum (each level having its own specific criteria and mandate). In 2011, more than half (52.9%) of the schools belonged to the bronze level and only 23.5% were at the gold level. Improvements were observed upon reassessment after 2 years (2013), with 76.4% of schools at the gold level and only 11.8% at bronze. CONCLUSIONS: The HPS accreditation system is feasible in school settings and was well implemented in the schools of Chandigarh. Improvements in accreditation scores between 2011 and 2013 suggest that the system may be effective in increasing levels of health promotion in communities.

A qualitative study on the perceptions of preventing falls as a health priority among older people in Northern India.

BACKGROUND: In India, fall-related injury morbidity and mortality is an emerging public health problem in older people. Despite awareness of a growing burden, there is a scarcity of literature on effective and acceptable interventions. This study was undertaken to explore the perceptions of older people regarding the risk of falls and understanding of fall prevention programmes. METHODS: We conducted six focus group discussions (FGDs), comprising single gender for three socio-demographic groups in a north Indian city, Chandigarh, in 2011. FGDs were conducted in local language (Punjabi), recorded, transcribed and translated in English. Two researchers independently conducted thematic analysis. RESULTS: Focus group participants were aware of the devastating consequences of fall-related injuries. The predominant reasons for explaining an increased risk of falling was age, uneven surfaces, physical weakness and mental health. There were several other competing health priorities in this population. Preventive measures ranging from individual to government level initiatives were suggested. The experience, knowledge, perceptions and health priorities were diverse among the three socio-demographic groups. However, the feasibility, acceptability and effectiveness for improving balance and strength using yoga in this population needs to be evaluated. CONCLUSIONS: Careful consideration of health priorities is required for development of falls prevention, particularly among the urban poor. Further, initiatives that foster community engagement, such as participatory action may increase acceptability of initiatives to prevent fall-related injury among older people in India.

Impact of policy initiatives on civil registration system in haryana.

BACKGROUND: Despite the existence of Registration of Birth and Death Act (1969), Civil Registration System (CRS) in India registered only 68.3% of the births and 63.2% of the deaths. Hence, National Population Policy (2000) emphasized the need to improve registration of vital events. In 2005, Haryana initiated policy changes to enhance registration of vital events. We evaluated the impact of these policy changes on CRS in 2009. MATERIALS AND METHODS: Records and reports of CRS were reviewed. On the basis of the birth and deaths reported by the Sample Registration System, the proportion of births and deaths registered by CRS were estimated using the projected population from 2001 Census. RESULTS: Before 2005, Police Stations were the registration centers in rural Haryana. On 1(st) January 2005, the birth and death registration was made the responsibility of Primary Health Centers (PHCs). Medical Officers at PHCs were designated as Registrar and Pharmacists as Sub-Registrar of Births and Deaths. Auxiliary Nurse Midwife and Anganwadi Workers facilitated the registration. Till 2004, the registration of births was stagnant at the level of 70% for several years, which increased to 95% by 2009. Similarly registration of death events increased from 73.5% to 92.1%. CONCLUSION: Haryana state is still to achieve complete registration of births and deaths, but certainly shift of registration from police to health department has strengthened the CRS.