Implementation of an evidence-based tobacco control intervention for school teachers in India: Evaluating the effects of a capacity-building strategy.

Background: Tobacco-Free Teachers, Tobacco-Free Society (TFT-TFS) is an evidence-based intervention that promotes tobacco use cessation among teachers and tobacco control policies among schools in India. This study tested an implementation model to build Bihar Department of Education (DOE) capacity to support and deliver TFT-TFS within schools, leveraging DOE training infrastructure. Method: We used a training-of-trainers (TOT) "cascade" implementation strategy to embed the TFT-TFS program into the Bihar DOE infrastructure. We trained 46 Cluster Coordinators to train and support Headmasters to implement TFT-TFS in their schools over one academic year. We selected three school districts, representing approximately 46 clusters and 219 schools. We used the RE-AIM framework to assess program adoption (Headmaster participation in at least one of six TFT-TFS trainings), implementation (of four core program components), and reach (teachers' participation in three or more group discussions). Using a non-inferiority design, we hypothesized that program adoption, implementation, and reach would not be inferior to the high standards demonstrated when TFT-TFS was originally tested in the Bihar School Teachers Study. We used self-reported checklists to measure outcomes and SPSS Version 25 to analyze data. Results: For adoption, 94% of Headmasters attended the first training, although participation declined by the sixth training. Among the 112 schools out of 219 with complete Headmaster checklist data, all met our minimum criteria for implementing TFT-TFS. Over 99% of schools posted a school tobacco control policy and distributed quit booklets. However, only 69% of schools met our criteria for program reach. Conclusions: This study outlines the processes for taking a tobacco control intervention to scale and implementing it through the Bihar DOE infrastructure. These findings provide a foundation for other Indian states and low- and middle-income countries to implement tobacco control and other health programs for schoolteachers. Trial registration: NCT05346991. Plain Language Summary: Each year in India, more than 1.2 million people die from tobacco-related causes, and India has the world's highest oral cancer burden. The world needs more evidence on how to bring cost-effective tobacco control interventions to scale, especially in low- and middle-income countries (LMICs). To address this gap, from 2017 to 2021, we examined the process of scaling up Tobacco-Free Teachers, Tobacco-Free Society (TFT-TFS), an evidence-based intervention promoting tobacco use cessation among teachers and tobacco control policies in schools. Our study tested an implementation model aimed at building the Bihar State Department of Education (DOE) capacity to support and deliver TFT-TFS. We used a training-of-trainers model to embed TFT-TFS into Bihar DOE infrastructure, training 46 Cluster Coordinators to in turn train and support Headmasters to implement TFT-TFS over one academic year. We hypothesized that program adoption, implementation, and reach would not be inferior to the high standards demonstrated when we originally tested TFT-TFS through the Bihar School Teachers Study (2013-2017). For adoption, 94% of Headmasters attended the first training, although participation declined by the sixth training. Of 112 schools (out of 219 with complete Headmaster checklist data), all met our minimum criteria for implementing TFT-TFS. Over 99% of schools posted a school tobacco control policy and distributed quit booklets. However, only 69% of schools met our criteria for program reach. Study findings offer other Indian states and LMICs lessons to implement tobacco control and other health programs for schoolteachers within educational systems.

Implementation of an organizational intervention to improve low-wage food service workers' safety, health and wellbeing: findings from the Workplace Organizational Health Study.

BACKGROUND: Many organizational interventions aim to improve working conditions to promote and protect worker safety, health, and well-being. The Workplace Organizational Health Study used process evaluation to examine factors influencing implementation of an organizational intervention. This paper examines the extent to which the intervention was implemented as planned, the dose of intervention implemented, and ways the organizational context hindered or facilitated the implementation of the intervention. METHODS: This proof-of-concept trial was conducted with a large, multinational company that provides food service through contractual arrangements with corporate clients. The 13-month intervention was launched in five intervention sites in October 2018. We report findings on intervention implementation based on process tracking and qualitative data. Qualitative data from 25 post-intervention interviews and 89 process tracking documents were coded and thematically analyzed. RESULTS: Over the 13-month intervention, research team representatives met with site managers monthly to provide consultation and technical assistance on safety and ergonomics, work intensity, and job enrichment. Approximately two-thirds of the planned in-person or phone contacts occurred. We tailored the intervention to each site as we learned more about context, work demands, and relationships. The research team additionally met regularly with senior leadership and district managers, who provided corporate resources and guidance. By assessing the context of the food service setting in which the intervention was situated, we explored factors hindering and facilitating the implementation of the intervention. The financial pressures, competing priorities and the fast-paced work environment placed constraints on site managers' availability and limited the full implementation of the intervention. CONCLUSIONS: Despite strong support from corporate senior leadership, we encountered barriers in the implementation of the planned intervention at the worksite and district levels. These included financial demands that drove work intensity; turnover of site and district managers disrupting continuity in the implementation of the intervention; and staffing constraints that further increased the work load and pace. Findings underscore the need for ongoing commitment and support from both the parent employer and the host client. TRIAL REGISTRATION: This study was retrospectively registered with the Clinical Trials. Gov Protocol and Results System on June 2, 2021 with assigned registration number NCT04913168 .

Using Total Worker Health® Implementation Guidelines to Design an Organizational Intervention for Low-Wage Food Service Workers: The Workplace Organizational Health Study.

Total Worker Health® (TWH) interventions that utilize integrated approaches to advance worker safety, health, and well-being can be challenging to design and implement in practice. This may be especially true for the food service industry, characterized by high levels of injury and turnover. This paper illustrates how we used TWH Implementation Guidelines to develop and implement an organizational intervention to improve pain, injury, and well-being among low-wage food service workers. We used the Guidelines to develop the intervention in two main ways: first, we used the six key characteristics of an integrated approach (leadership commitment; participation; positive working conditions; collaborative strategies; adherence; data-driven change) to create the foundation of the intervention; second, we used the four stages to guide integrated intervention planning. For each stage (engaging collaborators; planning; implementing; evaluating for improvement), the Guidelines provided a flexible and iterative process to plan the intervention to improve safety and ergonomics, work intensity, and job enrichment. This paper provides a real-world example of how the Guidelines can be used to develop a complex TWH intervention for food service workers that is responsive to organizational context and addresses targeted working conditions. Application of the Guidelines is likely transferable to other industries.

Ensuring Organization-Intervention Fit for a Participatory Organizational Intervention to Improve Food Service Workers' Health and Wellbeing: Workplace Organizational Health Study.

OBJECTIVE: Food-service workers' health and wellbeing is impacted by their jobs and work environments. Formative research methods were used to explore working conditions impacting workers' health to inform intervention planning and implementation and to enhance the intervention's "fit" to the organization. METHODS: Four qualitative methods (worker focus groups; manager interviews; worksite observations; multi-stakeholder workshop) explored in-depth and then prioritized working conditions impacting workers' health as targets for an intervention. RESULTS: Prioritized working conditions included: ergonomics; work intensity; career development; and job enrichment. Data revealed necessary intervention mechanisms to enhance intervention implementation: worker and management communication infrastructure; employee participation in intervention planning and implementation; tailored worksite strategies; and ensuring leadership commitment. CONCLUSIONS: These targeted, comprehensive methods move away from a typical focus on generic working conditions, for example, job demands and physical work environment, to explore those conditions unique to an organization. Thereby, enhancing "intervention-fit" at multiple levels within the company context.

Employee Perceptions of Safety, Health, and Well-Being: Focus Group Findings From One Veterans Affairs Medical Center.

OBJECTIVE: Focus groups were conducted at one veterans affairs (VA) medical center to understand (1) how the work environment and conditions of work influence employee safety, health, and well-being; (2) what programs, policies, and practices promote and protect employee safety and health in VA; and (3) how employee safety, health, and well-being impact the organizational mission. METHODS: Nine focus groups were conducted with leadership, supervisor, and frontline employees. Focus groups were audio recorded, transcribed, and content analysis was performed. RESULTS: Fifty-five employees participated in the focus groups. Six common themes emerged-stressful working conditions, health hazards, organizational factors, current program knowledge, participation barriers, and program suggestions. CONCLUSIONS: Employees identified organizational and structural elements of work that impact safety, health, and well-being. Application of the Total Worker Health™ hierarchy of controls provided a novel framework for discussion of focus group findings.

The relationship between organizational policies and practices and work limitations among hospital patient care workers.

OBJECTIVE: We examined relationships between organizational policies and practices (OPPs) (safety practices, ergonomic practices, and people-oriented culture) and work limitations in a sample of hospital workers. METHODS: We used the 6-item Work Limitations Questionnaire (WLQ) to assess workers' perceptions of health-related work limitations. Self-reported OPPs and the WLQ were collected from workers in Boston, Massachusetts (n = 1277). We conducted random-intercept multi-level logistic regression models for each OPP using stepwise selection of covariates. RESULTS: As the unit-average ergonomic practice score increased by one, the odds of a worker reporting work limitations decreased by approximately 39% (P-value = 0.018), adjusted for job title, age, and body mass index. A similar relationship existed for people-oriented culture (P-value = 0.038). The association between safety practices and work limitations was similar, but not statistically significant. CONCLUSIONS: This study demonstrated the importance of workplace OPPs. OPPs that promote positive and supportive environments and that foster improvements in ergonomics may help reduce work limitations.

Lost in translation: The challenge of adapting integrated approaches for worker health and safety for low- and middle-income countries.

OBJECTIVES: To describe the process of adapting an intervention integrating occupational safety and health (OSH) and health promotion for manufacturing worksites in India and the challenges faced in implementing it; and explore how globalization trends may influence the implementation of these integrated approaches in India and other low- and middle-income countries (LMICs). METHODS: This study-conducted in 22 manufacturing worksites in Mumbai, India-adapted and implemented an evidence-based intervention tested in the U.S. that integrated OSH and tobacco control. The systematic adaptation process included formative research and pilot testing, to ensure that the tested intervention was tailored to the local setting. We used qualitative methods and process evaluation to assess the extent to which this intervention was implemented, and to explore barriers to implementation. RESULTS: While participating worksites agreed to implement this intervention, not all components of the adapted intervention were implemented fully in the 10 worksites assigned to the intervention condition. We found that the OSH infrastructure in India focused predominantly on regulatory compliance, medical screening (secondary prevention) and the treatment of injuries. We observed generally low levels of leadership support and commitment to OSH, evidenced by minimal management participation in the intervention, reluctance to discuss OSH issues with the study team or workers, and little receptivity to recommendations resulting from the industrial hygienist's reports. CONCLUSION: India presents one example of a LMIC with a rising burden of non-communicable diseases and intensified exposures to both physical and organizational hazards on the job. Our experiences highlight the importance of national and global trends that shape workers' experiences on the job and their related health outcomes. Beyond a singular focus on prevention of non-communicable diseases, coordinated national and international efforts are needed to address worker health outcomes in the context of the conditions of work that clearly shape them.

Effects of a worksite tobacco control intervention in India: the Mumbai worksite tobacco control study, a cluster-randomised trial.

OBJECTIVES: We assessed a worksite intervention designed to promote tobacco control among workers in the manufacturing sector in Greater Mumbai, India. METHODS: We used a cluster-randomised design to test an integrated health promotion/health protection intervention, the Healthy, Safe, and Tobacco-free Worksites programme. Between July 2012 and July 2013, we recruited 20 worksites on a rolling basis and randomly assigned them to intervention or delayed-intervention control conditions. The follow-up survey was conducted between December 2013 and November 2014. RESULTS: The difference in 30-day quit rates between intervention and control conditions was statistically significant for production workers (OR=2.25, p=0.03), although not for the overall sample (OR=1.70; p=0.12). The intervention resulted in a doubling of the 6-month cessation rates among workers in the intervention worksites compared to those in the control, for production workers (OR=2.29; p=0.07) and for the overall sample (OR=1.81; p=0.13), but the difference did not reach statistical significance. CONCLUSIONS: These findings demonstrate the potential impact of a tobacco control intervention that combined tobacco control and health protection programming within Indian manufacturing worksites. TRIAL REGISTRATION NUMBER: NCT01841879.

Integrating worksite health protection and health promotion: A conceptual model for intervention and research.

There is increasing recognition of the value added by integrating traditionally separate efforts to protect and promote worker safety and health. This paper presents an innovative conceptual model to guide research on determinants of worker safety and health and to inform the design, implementation and evaluation of integrated approaches to promoting and protecting worker health. This model is rooted in multiple theories and the premise that the conditions of work are important determinants of individual safety and health outcomes and behaviors, and outcomes important to enterprises such as absence and turnover. Integrated policies, programs and practices simultaneously address multiple conditions of work, including the physical work environment and the organization of work (e.g., psychosocial factors, job tasks and demands). Findings from two recent studies conducted in Boston and Minnesota (2009-2015) illustrate the application of this model to guide social epidemiological research. This paper focuses particular attention on the relationships of the conditions of work to worker health-related behaviors, musculoskeletal symptoms, and occupational injury; and to the design of integrated interventions in response to specific settings and conditions of work of small and medium size manufacturing businesses, based on a systematic assessment of priorities, needs, and resources within an organization. This model provides an organizing framework for both research and practice by specifying the causal pathways through which work may influence health outcomes, and for designing and testing interventions to improve worker safety and health that are meaningful for workers and employers, and responsive to that setting's conditions of work.

Implementing an Integrated Health Protection/Health Promotion Intervention in the Hospital Setting: Lessons Learned From the Be Well, Work Well Study.

OBJECTIVE: This study reports findings from a proof-of-concept trial designed to examine the feasibility and estimates the efficacy of the "Be Well, Work Well" workplace intervention. METHODS: The intervention included consultation for nurse managers to implement changes on patient-care units and educational programming for patient-care staff to facilitate improvements in safety and health behaviors. We used a mixed-methods approach to evaluate feasibility and efficacy. RESULTS: Using findings from process tracking and qualitative research, we observed challenges to implementing the intervention due to the physical demands, time constraints, and psychological strains of patient care. Using survey data, we found no significant intervention effects. CONCLUSIONS: Beyond educating individual workers, systemwide initiatives that respond to conditions of work might be needed to transform the workplace culture and broader milieu in support of worker health and safety.

Social contextual factors and tobacco use among Indian teachers: insights from the Bihar School Teachers' Study.

OBJECTIVE: Tobacco use within India has significant effects on the global burden of tobacco-related disease. As role models and opinion leaders, teachers are at the forefront of tobacco control efforts, yet little is known about their own tobacco use. This study examines the association between factors in the social environment and tobacco use among teachers in Bihar, India. METHODS: The study was based on the Bihar School Teachers' Study baseline survey. Seventy-two Bihar government schools (grades 8-10) were randomly selected for the study and all school personnel were invited to complete the survey in June/July in 2009 and 2010. We assessed the relation between social contextual factors and current smoking/smokeless tobacco use by fitting a series of logistic regression models. RESULTS: After controlling for clustering of teachers in schools and other covariates, our results showed teachers with one or more coworkers who used tobacco were twice as likely to be smokeless tobacco users as teachers with no co-workers who used tobacco. Teachers who reported rules prohibiting smoking at home were significantly less likely to smoke than teachers without such rules. Older male teachers also had significantly greater odds of smoking/using smokeless tobacco. CONCLUSION: These findings provide direction for future interventions targeting the social context.

Designing in the social context: using the social contextual model of health behavior change to develop a tobacco control intervention for teachers in India.

This article provides a theory-based, step-by-step approach to intervention development and illustrates its application in India to design an intervention to promote tobacco-use cessation among school personnel in Bihar. We employed a five-step approach to develop the intervention using the Social Contextual Model of Health Behavior Change (SCM) in Bihar, which involved conducting formative research, classifying factors in the social environment as mediating mechanisms and modifying conditions, developing a creative brief, designing an intervention and refining the intervention based on pilot test results. The intervention engages users and non-users of tobacco, involves teachers in implementing and monitoring school tobacco control policies and maximizes teachers' role as change agents in schools and communities. Intervention components include health educator visits, discussions led by lead teachers, cessation assistance, posters and other educational materials and is implemented over the entire academic year. The intervention is being tested in Bihar government schools as part of a randomized-controlled trial. SCM was a useful framework for developing a tobacco control intervention that responded to teachers' lives in Bihar.

Correlates of fruit and vegetable consumption among construction laborers and motor freight workers.

PURPOSE: The aim of this study was to compare and contrast correlates of fruit and vegetable consumption in two blue-collar populations: construction laborers and motor freight workers. METHODS: Cross-sectional data were collected from two groups of male workers: (1) construction laborers (n = 1,013; response rate = 44 %) randomly selected from a national sample, as part of a diet and smoking cessation study; and (2) motor freight workers (n = 542; response rate = 78 %) employed in eight trucking terminals, as part of a tobacco cessation and weight management study. Data were analyzed using linear regression modeling methods. RESULTS: For both groups, higher income and believing it was important to eat right because of work were positively associated with fruit and vegetable consumption; conversely, being white was associated with lower intake. Construction laborers who reported eating junk food due to workplace stress and fatigue had lower fruit and vegetable intake. For motor freight workers, perceiving fast food to be the only choice at work and lack of time to eat right were associated with lower consumption. CONCLUSION: Comparing occupational groups illustrates how work experiences may be related to fruit and vegetable consumption in different ways as well as facilitates the development of interventions that can be used across groups.