Short-term nutrition and growth indicators in 6-month- to 6-year-old children are improved following implementation of a multidisciplinary community-based programme in a chronic conflict setting

Objective: We investigated short- and long-term indicators of malnutrition and diet before and after the community-based ‘Breaking the Cycle of Poverty’ multidisciplinary intervention. Design: A historically and geographically controlled study using data collected in 2013 and 2016. We compared the prevalence of short-term indicators (anaemia, breast-feeding duration and minimum dietary diversity) and long-term indicators (stunting and wasting) in exposed communities at two time points. We then compared these factors in geographic areas exposed or not exposed to intervention. We conducted logistic regression analyses on the 2016 sample to measure associations between living in intervention communities and child growth indicators. Setting: Berd region, a chronic conflict zone near the north-eastern border of Armenia and Azerbaijan. Participants: Children aged 6 months to 6 years. Results: Analyses included data from 2013 comprising 382 children, and data from 2016 comprising 348 children living in communities where the programme was implemented, and 635 children from unexposed communities. Anaemia prevalence in exposed communities was significantly lower in 2016 v. 2013 (10·9 v. 19·1 %, P < 0·01). Minimum dietary diversity (79·0 v. 68·1 %, P < 0·001) and breast-feeding duration (13·0 v. 11·5 months, P < 0·002) were significantly improved in exposed communities. Prevalences of stunting (11·5 v. 10·2 %, P = 0·57) and wasting (4·8 v. 2·0 %, P = 0·07) were not significantly different. Odds of anaemia were significantly lower (OR = 0·24, 95 % CI 0·16, 0·36) in intervention communities. Conclusions: Exposure to a community-based multidisciplinary intervention reduced the rate of anaemia and improved dietary indicators

What 'outliers' tell us about missed opportunities for tuberculosis control: a cross-sectional study of patients in Mumbai, India

BACKGROUND: India's Revised National Tuberculosis Control Programme (RNTCP) is deemed highly successful in terms of detection and cure rates. However, some patients experience delays in accessing diagnosis and treatment. Patients falling between the 96th and 100th percentiles for these access indicators are often ignored as atypical 'outliers' when assessing programme performance. They may, however, provide clues to understanding why some patients never reach the programme. This paper examines the underlying vulnerabilities of patients with extreme values for delays in accessing the RNTCP in Mumbai city, India. METHODS: We conducted a cross-sectional study with 266 new sputum positive patients registered with the RNTCP in Mumbai. Patients were classified as 'outliers' if patient, provider and system delays were beyond the 95th percentile for the respective variable. Case profiles of 'outliers' for patient, provider and system delays were examined and compared with the rest of the sample to identify key factors responsible for delays. RESULTS: Forty-two patients were 'outliers' on one or more of the delay variables. All 'outliers' had a significantly lower per capita income than the remaining sample. The lack of economic resources was compounded by social, structural and environmental vulnerabilities. Longer patient delays were related to patients' perception of symptoms as non-serious. Provider delays were incurred as a result of private providers' failure to respond to tuberculosis in a timely manner. Diagnostic and treatment delays were minimal, however, analysis of the 'outliers' revealed the importance of social support in enabling access to the programme. CONCLUSION: A proxy for those who fail to reach the programme, these case profiles highlight unique vulnerabilities that need innovative approaches by the RNTCP. The focus on 'outliers' provides a less resource- and time-intensive alternative to community-based studies for understanding the barriers to reaching public health programmes

Hookah use among adolescent school students from urban slums of Mumbai, India

Introduction "Hookah" or waterpipe smoking is becoming popular among youth. It is addictive and associated with multiple, long-term, adverse health outcomes. Availability of flavored hookah, increasing social acceptability, influence of tobacco industry and misconceptions about hookah have contributed to its increasing use among youth. Many adolescents from urban slums of Mumbai do not know that hookah contains tobacco. The aim of the study was to assess the prevalence of hookah and factors associated with its cessation among adolescents from slums of Mumbai. Methods LifeFirst is a tobacco/areca-nut dependence treatment program implemented in 40 schools in slum areas of Mumbai in 2017-18. 4302 students of 7th-9th grades attended orientation sessions about tobacco products including hookah and their harmful effects. Students were informed about the availability of a cessation service and encouraged to register voluntarily for six theme-based group sessions conducted over six months. At the end of the six sessions, cessation outcomes were recorded. Results Of the 1441 students registered for tobacco/areca-nut cessation, 6% were current hookah users (3% of boys and 7% of girls). 65% of them initiated hookah use because of curiosity and 25% due to peer influence. Of the current hookah users, 8% smoked hookah daily. At the end of six sessions, 54% of the hookah users reported stopping smoking hookah while the abstinence was 72% among the rest of the students. Conclusions Hookah smoking is prevalent among school-going adolescents from slums of Mumbai and school-based cessation programs are required to increase awareness and support them to quit

Sociodemographic factors, attitudes, and tobacco use among adolescent areca-nut users in Mumbai, India

Introduction: Areca nut, initiated in adolescence, is considered a gateway for tobacco use and an important cause of oral cancers in India. This study examined differences in sociodemographic factors, attitudes and beliefs, and tobacco use between current (last 30 days) areca nut users and past users, who have ever used areca but not in the last 30 days. Material and Methods: A cross-sectional survey with school students attending grades 7, 8, 9 provided data to compare differences in age, gender, beliefs, attitudes, and concurrent tobacco use among self-reported areca users. Of 1909 participants surveyed, 641 (33.57%) reported use of areca nut; of which 355 (55.38%) current users had consumed it in the last 30 days. Results: A logistic regression model revealed that male gender, using tobacco concurrently, inability to refuse a friend's request to use, and intention to use areca nuts in the next 12 months were significant predictors of current areca use. Conclusion: More research is needed to understand adolescent areca-nut use, including different types of users such as experimenters and those with established habits. This will help design targeted areca-nut prevention and cessation programs

Tobacco and areca nut cessation programme for adolescent school students in Mumbai, India

Background The prevalence of tobacco use among children aged 13-15 years is 14.6% and 15.5% of non-users intended to start smoking in the next year. School going children also consume areca nut (“supari”), which is an easily available carcinogenic, psychoactive substance, acting as a gateway product to tobacco use. This current and intended use will exacerbate the burden of tobacco related morbidity and mortality. LifeFirst program was implemented in 15 schools catering to lower socioeconomic population in slum areas of Mumbai in the academic year 2016-17 for helping students quit their tobacco and supari use. Methods Orientation sessions about harmful effects of tobacco and areca nut were conducted using audio-visual aids for 2379 students of the 7th, 8th and 9th grades. Students were informed about the availability of a cessation service within the school and encouraged to register voluntarily. The registered students were divided into groups of 10-15 students each and six group-sessions involving videos, games, role plays and activities were conducted over six months. The sessions were theme based; covering topics like rapport building, ill-effects of tobacco, coping mechanisms, refusal skills etc. The self-reported status of tobacco use was recorded individually during each session. Extended 4-month post-program follow-up was conducted. Results Of the 492 students (84% boys) registered for the program, 88% were only supari users, 10% used supari and tobacco, 2% only smokeless and less than 1% only smoked. 67% were daily users. The mean age of initiation was 11.7 years and 79% were introduced to the product by their peers. 71% reported as not using tobacco and supari at the end of the programme with 12% relapse recorded during extended follow up. Conclusions Providing structured cessation services with positive peer influence facilitated by trained counselors encourages and aides tobacco and areca nut users to stop their habit

Moving towards a tobacco free workplace at a cement manufacturing plant in Chandrapur, Maharashtra

Background According to Global Adult Tobacco Survey -2, 267 million adults consume tobacco in some form in India and 75% of them use smokeless tobacco. Smoking is banned in India in public places including indoor workplaces under the Cigarettes and Other Tobacco Products Act (COTPA). However, there are no regulations for smokeless tobacco use, the most prevalent form. Workplaces offer a unique opportunity to address employees' health and influence their tobacco use behavior. LifeFirst tobacco cessation service was provided at a cement plant with about 2000 employees in Chandrapur, Maharashtra with the objective of promoting and aiding quit attempts of tobacco users. Methods An awareness talk about tobacco and its ill effects and benefits of quitting was provided in groups to 1764 employees (all males). Employees voluntarily registered for the cessation service which included a detailed face to face counseling session followed by four follow up sessions over six months. Tobacco use status was recorded at each session. In addition to this, trainings for “Anti-tobacco champions” and the Medical Team were conducted for incorporating the initiative into the company's Occupational Health activities. An announcement was made by the plant head to make the plant tobacco free within a year. Results 648 employees voluntarily registered for the cessation service. 607(94%) of these were smokeless tobacco users, majority (77%) of them using the local tobacco product “kharra” (mixture of tobacco and areca nut). 552(85%) attended the follow up session at 6 months and 438(68%) of all registered users reported not using any form of tobacco, 50(8%) had reduced use, 60(9%) had made a quit attempt but relapsed. Conclusions By providing tobacco cessation activities within a workplace, employees using smokeless tobacco as well as smoking can be helped to quit their tobacco habit and create an environment conducive to a tobacco free workplace

Perceptions of permanent and contractual employees about a tobacco free workplace policy among four workplaces in Maharashtra, India

Background Cigarettes and Other Tobacco Products Act, (COTPA) prohibits smoking in public places including indoor workplaces. Despite this, few workplaces in India have documented tobacco free workplace policies being implemented. The policy influences employees about their tobacco use behavior. However, before implementing such a policy, it is important to assess perceptions and readiness of employees. A situational analysis survey was conducted among employees of four organisations to know their readiness about having a policy, their self-reported tobacco use and the need of counseling support to quit tobacco. Methods A structured questionnaire was administered online to 447 permanent staff while face-to-face interviews were conducted among 281 contractual workers from August 2016 to March 2017. Results Majority of permanent and contractual workers agreed that the organization should have a tobacco free policy and that it will have a positive impact on the employees' health. Equal proportion of permanent (55%) and contractual staff (54%) were aware of the existing rules and among them, 84% and 86% respectively were satisfied with them. 26% of permanent and 56% of contractual staff self-reported ever using some form of tobacco while 9% and 38% respectively reported current tobacco use (last 30 days). Fewer contractual (79%) as compared to permanent staff (89%) felt that some action should be taken against violation of the policy. Monetary fine and written warnings were suggested as action by majority from both groups. More contractual (98%) than permanent staff (84%) reported that there should be counseling service at the workplace for tobacco users. Conclusions Both contractual and permanent employees endorsed the need for a tobacco free workplace policy with penal action for violations. However, the differences in tobacco use and perceptions towards the policy of these two groups have to be considered while implementing the policy and offering cessation services

Introducing tobacco free workplace policy in workplaces in India - challenges and learning

Background and challenges to implementation While smoking is prohibited in India in public places and indoor workplaces, there is no regulation about smokeless tobacco use in workplaces as per the Cigarette and Other Tobacco Products Act. Very few companies in India have a documented tobacco free workplace policy addressing smokeless tobacco use. Narotam Sekhsaria Foundation was selected for implementing Clinton Global Initiative's Tobacco free workplace policy challenge project focusing on India and including smokeless tobacco use. Five workplaces in Maharashtra with total 5000 employees were approached to be a part of this project. Intervention or response Activities involved a situational analysis, provision of cessation service and formulation and implementation of a policy document according to the guidelines "Smokefree-in-a-box" toolkit developed by the Global Smokefree Partnership. Results and lessons learnt The policy was launched and implemented in only one workplace during one year and 332 employees were provided cessation counselling. Lessons learnt: · Organizations are willing to get involved on a pilot basis in representative units and not willing to for the entire company. · They are interested in the tobacco free policy from the point of view of employee wellness · Organizations are not ready to commit for policy before the cessation services. · Management employees are reluctant to enroll for the cessation services · Coordination with a number of departments at the company level is required. · Proper and effective communication to all employees regarding the tobacco free policy by the decision makers is required. · Integration of tobacco free workplace activities with their internal processes (e.g. Ocuupational Health and Safety, Annual Medical Checkup etc.) ensures acceptability Conclusions and key recommendations Implementing a tobacco-free workplace policy in India is required but challenging. It creates an environment conducive to behavioural change and cessation among employees. Integrating it with internal systems and effective communication from the decision makers makes it feasible to implement