Feasibility randomised controlled trial of face-to-face counselling and mobile phone messages compared to usual care for smokeless tobacco cessation in Indian primary care: Project CERTAIN.

INTRODUCTION: Smokeless tobacco (SLT) use in low- and middle-income countries (LMICs) has adverse health consequences. We hypothesize that it is feasible to test an intervention of mobile phone messages and face-to-face counselling session for SLT cessation in India. METHODS: We conducted an exploratory, individual parallel two group, randomised controlled trial (RCT), with baseline -and end-point (three months from randomisation) assessments in urban primary health centres in Odisha, India. A total of 250 current (i.e., users in the last three months) SLT users or dual users (i.e., smokers and SLT users) were recruited to the trial (125 in each group). Participants were randomised to either routine care, face-to-face counselling, and reminder mobile messages or routine care only. The primary outcomes were to assess the feasibility of running a full RCT including recruitment, compliance, and retention. RESULTS: A total seven (77.8%) out of nine primary care centres took part in the trial. Out of the 315 SLT users invited to participate, 250 provided consent and were randomised [79.4% (95% CI: 74.5, 83.7)]. Out of the 250 randomised SLT users, 238 [95% (95% CI: 91.8, 97.5)] were followed up at three months (117 in the intervention group and 121 in the control group). Of the participants in the intervention group, 74 (63.8%) reported that they received the mobile messages. CONCLUSIONS: This exploratory trial demonstrated the feasibility of delivering and evaluating an intervention of mobile phone messages and face-to-face counselling for SLT users in Indian primary care in a full randomised trial. IMPLICATIONS: This study found that combining mobile messages with face-to-face counselling for smokeless tobacco users visiting primary health care settings in India is feasible in terms of recruitment of users, compliance with the intervention, and retention of study participants within the trial.The biochemically verified smokeless tobacco abstinence rate was higher in the intervention group compared with the control groupThere was poor agreement between self-reported tobacco cessation and the measured salivary cotinine in smokeless tobacco users.The findings support the feasibility and acceptability of the intervention signalling the need for a larger clinical trial to test effectiveness of the intervention.

A mixed methods evaluation of the impact of ECHO® telementoring model for capacity building of community health workers in India.

INTRODUCTION: India has the largest cohort of community health workers with one million Accredited Social Health Activists (ASHAs). ASHAs play vital role in providing health education and promoting accessible health care services in the community. Despite their potential to improve the health status of people, they remain largely underutilized because of their limited knowledge and skills. Considering this gap, Extension for Community Healthcare Outcomes (ECHO)® India, in collaboration with the National Health System Resource Centre (NHSRC), implemented a 15-h (over 6 months) refresher training for ASHAs using a telementoring interface. The present study intends to assess the impact of the training program for improving the knowledge and skills of ASHA workers. METHODS: We conducted a pre-post quasi-experimental study using a convergent parallel mixed-method approach. The quantitative survey (n = 490) assessed learning competence, performance, and satisfaction of the ASHAs. In addition to the above, in-depth interviews with ASHAs (n = 12) and key informant interviews with other stakeholders (n = 9) examined the experience and practical applications of the training. Inferences from the quantitative and qualitative approaches were integrated during the reporting stage and presented using an adapted Moore's Expanded Outcomes Framework. RESULTS: There was a statistically significant improvement in learning (p = 0.038) and competence (p = 0.01) after attending the training. Participants were satisfied with the opportunity provided by the teleECHO™ sessions to upgrade their knowledge. However, internet connectivity, duration and number of participants in the sessions were identified as areas that needed improvement for future training programs. An improvement in confidence to communicate more effectively with the community was reported. Positive changes in the attitudes of ASHAs towards patient and community members were also reported after attending the training. The peer-to-peer learning through case-based discussion approach helped ensure that the training was relevant to the needs and work of the ASHAs. CONCLUSIONS: The ECHO Model ™ was found effective in improving and updating the knowledge and skills of ASHAs across different geographies in India. Efforts directed towards knowledge upgradation of ASHAs are crucial for strengthening the health system at the community level. The findings of this study can be used to guide future training programs. Trial registration The study has been registered at the Clinical Trials Registry, India (CTRI/2021/10/037189) dated 08/10/2021.

Validation of Mobile Messages for an mHealth Intervention for Smokeless Tobacco Cessation in India.

BACKGROUND: With the growth in use of mobile messages for behaviour change, the need to incorporate personal needs and cultural characteristics of target users has been promoted. The study aimed to describe the findings of content validation of mobile messages designed to promote smokeless tobacco cessation in primary care. METHODS: This study used a concurrent mixed-method approach with 13 patients who were tobacco users at urban primary care clinics. The clarity and appeal of 32 messages were rated on a Likert scale from 1 to 10. A mean clarity and appeal score per message was generated. A 5-item discussion guide was used for in-depth interviews and data was analysed using framework analysis. RESULTS: Participants found the content of the messages useful, and preferred shorter and audio formatted messages. The clarity scores for the messages ranged from 7.9 to 9.4 with an average score of 8.7 (SD 0.5). The appeal scores ranged from 7.3 to 9.2, with an average score of 8.5 (SD 0.6). CONCLUSIONS: Twenty-six from a total of 32 messages were found appropriate and finalised for use. This methodology can be used when developing contextually relevant mobile message interventions in other low resource settings.

Designing a mobile health smokeless tobacco cessation intervention in Odisha, India: User and provider perspectives.

Objective: There is limited evidence on the development of mobile health (mHealth) interventions for smokeless tobacco (SLT) cessation, despite its widespread use in South Asia. This formative qualitative study explored the perceptions of tobacco users and healthcare providers (HCPs) regarding developing a mHealth intervention for SLT cessation. Methods: This was a qualitative study using in-depth interviews (IDIs) with tobacco users (n = 26) and primary care physicians (PCPs) (n = 5) and focus group discussions (FGDs) with counsellors (n = 2) in four urban primary health centres (UPHCs) in Berhampur, Odisha from February to March 2020. The data were coded and analysed by two researchers using a framework analysis method. The discussion guides and initial codes were developed based on the Transtheoretical Model (TTM) of behaviour change. Results: The results were elaborated under four themes: (1) Current scenario of SLT use; (2) Barriers and facilitators for quitting SLT; (3) Barriers and facilitators for mHealth counselling; and (4) Design and delivery of the proposed intervention. SLT use was prevalent in the community regardless of sociodemographic factors. Peer factors accounted for both tobacco consumption as well as considering cessation. Participants considered mobile message counselling helpful and acceptable. Not having a mobile phone and illiteracy were identified as barriers while ease of access and rising popularity of social media applications were considered facilitators to the use of mHealth for quitting tobacco. Participants preferred messages that were pictorial, short and simple, in the local language, and tailored to individual's needs. Conclusions: This is the first study that provides evidence within the Indian context that the text messaging platform may be used for delivering an SLT cessation intervention. The integration of a theoretical basis and research findings from target users can guide future intervention development.

Role of multiresolution vulnerability indices in COVID-19 spread in India: a Bayesian model-based analysis.

OBJECTIVES: COVID-19 has differentially affected countries, with health infrastructure and other related vulnerability indicators playing a role in determining the extent of its spread. Vulnerability of a geographical region to COVID-19 has been a topic of interest, particularly in low-income and middle-income countries like India to assess its multifactorial impact on incidence, prevalence or mortality. This study aims to construct a statistical analysis pipeline to compute such vulnerability indices and investigate their association with metrics of the pandemic growth. DESIGN: Using publicly reported observational socioeconomic, demographic, health-based and epidemiological data from Indian national surveys, we compute contextual COVID-19 Vulnerability Indices (cVIs) across multiple thematic resolutions for different geographical and spatial administrative regions. These cVIs are then used in Bayesian regression models to assess their impact on indicators of the spread of COVID-19. SETTING: This study uses district-level indicators and case counts data for the state of Odisha, India. PRIMARY OUTCOME MEASURE: We use instantaneous R (temporal average of estimated time-varying reproduction number for COVID-19) as the primary outcome variable in our models. RESULTS: Our observational study, focussing on 30 districts of Odisha, identified housing and hygiene conditions, COVID-19 preparedness and epidemiological factors as important indicators associated with COVID-19 vulnerability. CONCLUSION: Having succeeded in containing COVID-19 to a reasonable level during the first wave, the second wave of COVID-19 made greater inroads into the hinterlands and peripheral districts of Odisha, burdening the already deficient public health system in these areas, as identified by the cVIs. Improved understanding of the factors driving COVID-19 vulnerability will help policy makers prioritise resources and regions, leading to more effective mitigation strategies for the present and future.

Evaluation of COVID-19 ECHO training program for healthcare workers in India - A Mixed-Method Study.

BACKGROUND: The Coronavirus Disease 2019 (COVID-19) has severely challenged healthcare delivery systems worldwide. Healthcare Workers were unable to assess and manage the cases due to limited knowledge of treating the virus and inadequate infrastructure. Digital interventions played a crucial role in the training of healthcare workers to get through the pandemic. Project Extension for Community Healthcare Outcomes (ECHO) initiated the COVID-ECHO telementoring program for strengthening the knowledge and skills of healthcare workers. The study aimed at assessing the effects of the ECHO telementoring model in the capacity building of healthcare workers in the context of COVID-19 in India. METHOD: We adopted a mixed-method approach with a parallel combination design. A quantitative survey was used to measure changes in the knowledge and self-efficacy among doctors and nurses. In-depth Interviews were used for qualitative exploration of perceptions and experiences of all the study participants. Student t-test and ANOVA were used to assess significant differences between mean scores across participant characteristics for different themes. Statistical significance was set at p < 0.05. In-depth Interviews were analyzed using Framework Analysis. The evaluation followed the first five levels of Moore's model. RESULTS: The results highlighted the strengthening of knowledge and skills of healthcare workers in the assessment and management of COVID-19 after the ECHO training. Learning and performance ratings were high as 96% reported an increase in knowledge and 98% were able to apply it in their clinical practices. The key challenges identified were technical issues like internet connectivity and lack of interaction due to limited visual connection. The hybrid sessions, use of video camera, feedback mechanism, and inclusion of Continuing Medical Education were recommended by participants to improve the model. CONCLUSIONS: The findings of this study are an important addition to the pre-existing literature supporting the replicability of the ECHO model in the upskilling of healthcare professionals working in underserved and remote areas, not only in the context of COVID-19 but also in other public health domains. To enhance the effectiveness of this ECHO model, the study findings may be used to refine the model and improve the areas of concern.

Patient Satisfaction with Quality of Primary Care Health services-findings from India.

BACKGROUND: Patient satisfaction is an essential indicator for measuring the quality of care. This study assessed patients' satisfaction with primary care services across different public health care system levels. METHODS: The study was a cross-sectional study conducted across three states in India. We adopted a multi-stage stratified random sampling technique to select the districts(n-13) and facilities (n-55). A total of 4650 patients' exit interviews were conducted. Linear regression and analysis of variance was used to test the association. Analyses was performed using Stata software (version 15.0). RESULTS: Patients visiting the primary facilities were more satisfied within the different domains of quality indicators that is, technical, communication, safety and cleanliness, and cost of services. The highest differences were observed on behaviour of other staff (Reg Coefficient 4.1 ± 0.8) and cleanliness of the ward (Reg Coefficient 4.0 ± 0.9). Significant negative association was observed in patient's satisfaction in the state of Kerala with an increase in age and education level. CONCLUSION: Our study suggests higher satisfaction at primary care facilities as compared to secondary and tertiary level facilities in the three states. Development of standardized tool and specific research on patient experience and its relation to the quality of care is needed in low- and middle-income countries.

Adherence Clubs to Improve Hypertension Management in Nigeria: Clubmeds, a Feasibility Study.

Background: Hypertension control remains a significant challenge in reducing the cardiovascular disease burden worldwide. Community peer-support groups have been identified as a promising strategy to improve medication adherence and blood pressure (BP) control. Objectives: The study aimed to evaluate the feasibility and impact of adherence clubs to improve BP control in Southeast Nigeria. Methods: This was a mixed-methods research involving a formative (pre-implementation) research, pilot study and process evaluation. Hypertensive patients in two communities were recruited into peer-support adherence clubs under the leadership of role-model patients to motivate and facilitate medication adherence, BP monitoring, and monthly medication delivery for six months. The primary outcome was medication adherence measured using visual analogue scale (VAS), with BP level at six months as a key secondary outcome. Results: We recruited a total of 104 participants. The mean age was 56.8 (SD-10.7) years, 72 (69.2%) were women, mean BP was 146.7 (SD-20.1)/86.9 (SD-11.2) mmHg, and the mean percentage of medication adherence on the VAS was 41.4% (SD-11.9%). At six months, 67 patients were assessed; self-reported adherence on the VAS increased to 57.3% (SD-25.3%) (mean difference between baseline and follow-up of 15.5%, p < 0.0001), while the mean BP decreased to 132.3 (SD-22.0)/82.9 (SD-12.2) mmHg (mean difference of 13.0 mmHg in systolic BP, p < 0.0001 and of 3.6 mmHg in diastolic BP, p = 0.02). Five in-depth interviews and four focus groups discussions were conducted as part of the qualitative analyses of the study. The participants saw hypertension as a big issue, with many unaware of the diagnosis, and they accepted the CLUBMEDS differential service delivery (DSD) model concept in hypertension. Conclusions: The study demonstrates that the implementation of adherence clubs for hypertension control is feasible and led to a statistically significant and clinically meaningful improvement in self-reported medication adherence, resulting in BP reduction. Upscaling the intervention may be needed to confirm these findings.

Exploratory randomised trial of face-to-face and mobile phone counselling against usual care for tobacco cessation in Indian primary care: a randomised controlled trial protocol for project CERTAIN.

INTRODUCTION: Despite widespread use of smokeless tobacco products by people within the Indian subcontinent, there is little awareness among Indians of its health hazards when compared with smoked tobacco. We hypothesise that mobile phone counselling will be feasible and effective for smokeless tobacco cessation intervention in India. This paper presents the protocol of the development and conduct of an exploratory trial before progression to a full randomised controlled trial. METHODS AND ANALYSIS: An exploratory randomised controlled trial will be conducted in urban primary health centres in the state of Odisha, India. A total of 250 smokeless tobacco users will be recruited to the study (125 in each arm). Participants in the intervention arm will receive routine care together with a face-to-face counselling intervention followed by advice and reminder mobile messages. The control arm will receive routine care, delivered by a primary care physician based on 'Ask' and 'Advice'. All participants will be followed up for 3 months from the first counselling session. The primary outcome of this trial is to assess the feasibility to carry out a full randomised controlled trial. ETHICS AND DISSEMINATION: Ethical approvals were obtained from the Institutional Ethics Committee of Public Health Foundation of India, Health Ministry's Screening Committee, Odisha State Ethics Board and also from University College London Research Ethics Committee, UK. The study findings will be published in a peer-reviewed scientific journal. TRIAL REGISTRATION NUMBER: CTRI/2019/05/019484.

What are the determinants of childhood infections in India's peri-urban slums? A case study of eight cities.

BACKGROUND: Respiratory Tract Infections (RTIs) and Gastro-Intestinal (GI) infections are the leading causes of child mortality and morbidity. This study investigates the associations between the individual, household and slum-level determinants of children's health and vulnerability to RTIs and GI infections in peri-urban slums in India; an area of research interest at the Childhood Infections and Pollution Consortium. METHODS: The 2015-16 Indian National Family Health Survey was used for data analysis on children aged 0-5 years. NFHS-4 includes data on slums in eight Indian cities, including Delhi, Meerut, Kolkata, Indore, Mumbai, Nagpur, Hyderabad, Chennai. The outcome variables, having fever and cough (FeCo) and diarrhoea in the last two weeks, were used to define the phenotype of infections; for this analysis fever and cough were measures of RTIs and diarrhoea was used to measure GI infections. Exposures considered in this study include variables at the individual, household and slum level and were all informed by existing literature. Multilevel models were used to estimate the association between exposures and outcomes variables; a prior of Cauchy distribution with a scale of 2.5 was selected when building the multilevel logistic models. RESULTS: The total sample size of the number of children included in the analysis was n = 1,424. Data was imputed to account for missingness, and the original and imputed sample showing similar distributions. Results showed that diarrhoea and FeCo were both found to be more present in younger children than older children by a few months. In fixed effects, the odds of developing FeCo were higher if the mother perceives the child was born smaller than average (AOR 4.41, 1.13-17.17, P<0.05) at individual level. On the other hand, the odds of the diarrhoea outcome were lower if the child was older (AOR 0.97, 0.96-0.98, P<0.05) at individual level, and household's water source was public tap or standpipe (AOR 0.54, 0.31-0.96, P<0.05) at household level. CONCLUSION: The determinants of health, both social and related to health care, at all levels demonstrated linkages to child morbidity in RTIs and GI infections. The empirical evidence highlights the need for contextualised ideas at each level, including one health approach when designing interventions to improve child health.

Salt intake and salt-reduction strategies in South Asia: From evidence to action.

The World Health Organization recommends salt reduction as a cost-effective intervention to prevent noncommunicable diseases. Salt-reduction interventions are best tailored to the local context, taking into consideration the varying baseline salt-intake levels, population's knowledge, attitude, and behaviors. Fundamental to reduction programs is the source of dietary salt-intake. In South Asian countries, there is a paucity of such baseline evidence around factors that contribute to community salt intake. Upon reviewing the electronic literature databases and government websites through March 31, 2021, we summarized dietary salt intake levels and aimed to identify major sources of sodium in the diet. Information on the current salt reduction strategies in eight South Asian countries were summarized, namely Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka. One hundred twelve publications (out of identified 640) met our inclusion-exclusion criteria for full text review. Twenty-one studies were included in the review. Quality of the included studies was assessed using the US National Heart, Lung, and Blood Institute assessment tool. The primary result revealed that mean salt intake of South Asian countries was approximately twice (10 g/day) compared to WHO recommended intake (< 5 g/day). The significant proportion of salt intake is derived from salt additions during cooking and/or discretionary use at table. In most South Asian countries, there is limited data on population sodium intake based on 24-h urinary methods and sources of dietary salt in diet. While salt reduction initiatives have been proposed in these countries, they are yet to be fully implemented and evaluated. Proven salt reduction strategies in high-income countries could possibly be replicated in South Asian countries; however, further community-health promotion studies are necessary to test the effectiveness and scalability of those strategies in the local context.

Does behavioral intervention affect intention to quit? : A quasi-experimental study from primary healthcare settings in India.

INTRODUCTION: Tobacco is the leading cause of death and disease in India. This study examines the effect of training intervention in behavioral counseling on intention to quit tobacco in primary healthcare settings in India. The intervention included training to improve behavioral counseling practices of primary care physicians (PCPs) based on the 5As approach to increase patients' motivation to quit tobacco. METHODS: A quasi-experimental design was used for the study. The intervention consists of training of primary care physicians in the behavioral intervention in tobacco cessation. The intervention was conducted in twelve districts of two states in India (Rajasthan and Odisha) in 2016-2017. Four districts were randomly sampled for the study. A total of 1314 participants (intervention and control) were recruited for the study in the baseline and end-line surveys, respectively. Intention to quit in 30 days was the primary outcome measure. Difference-in-difference (DiD) logistic regression models were used separately for smokers and smokeless tobacco users to estimate the odds of intention to quit. Analysis was done in STATA Version 14. RESULTS: The intervention and time variable had a significantly positive influence on the intention to quit tobacco among smokers. Smokers in the intervention districts had higher odds of intention to quit (OR=9.82; 95% CI: 1.67-57.72) compared to smokers in the control districts. Smokeless tobacco (SLT) users had higher odds of intention to quit (OR=3.06; 95% CI: 1.35-6.98) in the end-line survey compared to baseline survey. CONCLUSIONS: Our findings indicate that building capacity in behavioral intervention in primary care settings can help increase the intention to quit among smokers. The observed difference in intention to quit between smokers and SLT users suggests the need of tailored counseling interventions for SLT users. There is a need for further research to design and evaluate training and behavioral interventions for SLT and dual (smoking and SLT) users in primary care settings in low- and middle-income countries.

Incremental Benefits of Multiple Tobacco Control Interventions: A Factorial Randomized Control Trial.

Tobacco control requires a comprehensive approach. The present study aims to examine the incremental effectiveness of health systems intervention when combined with other interventions in enhancing knowledge and practices of physicians in tobacco cessation. METHODS: A randomized control trial was conducted among 437 physicians in 12 districts of two states of India in 2011-13. The interventions consisted of Health Systems (H), Community (C) and Youth intervention (Y). Administrative Blocks /Mandals were randomly assigned to one of the three interventions (HC /HCY/HY) and control units. The health system intervention consisted of training physicians and developing a system of patient support and supervision for tobacco cessation. The primary outcome was change in knowledge and practices of physicians in tobacco cessation. Logistic regression model was applied to assess the impact of single and combination of interventions. RESULTS: An increase in knowledge was observed on effects of tobacco on adverse birth outcomes, advice on NRT and, information provided on chronic disease management among physicians in HC, HY and HCY intervention units compared to control units from pre-intervention to post-intervention. Statistically significant change was observed in knowledge of physicians on effects of tobacco on adverse birth outcomes in HC (OR- 4.75, p-0.02) and HCY (OR- 5.08, p-0.04) intervention units. CONCLUSIONS: HCY intervention was most effective in enhancing knowledge and practices of physicians in tobacco cessation. Our study suggests that individual tobacco control interventions when combined together has an incremental effect and increases the likelihood of provision of tobacco cessation services in primary care. 
.

Adapting a club-based medication delivery strategy to a hypertension context: the CLUBMEDS Study in Nigeria.

INTRODUCTION: The prevalence of hypertension in sub-Saharan Africa is among the world's highest; however, awareness, treatment and control of hypertension in this region are suboptimal. Among other barriers, the overburdened healthcare system poses a great challenge for hypertension control. Community peer-support groups are an alternative and promising strategy to improve adherence and blood pressure (BP) control. The CLUBMEDS study aims to evaluate the feasibility and impact of adherence clubs to improve hypertension control in Nigeria. METHODS AND ANALYSIS: The CLUBMEDS study will include a formative (pre-implementation) qualitative evaluation, a pilot study and a process (postimplementation) qualitative evaluation. At the formative stages, focus group discussions with patient groups and in-depth interviews with healthcare providers, managers and key decision makers will be conducted to understand the feasibility, barriers and facilitators, opportunities and challenges for the successful implementation of the CLUBMEDS strategy. The CLUBMEDS pilot study will be implemented in two primary healthcare facilities, one urban and one rural, in Southeast Nigeria. Each adherence club, which consists of a group of 10-15 patients with hypertension under the leadership of a role-model patient, serves as a support group to encourage and facilitate adherence, BP self-monitoring and medication delivery on a monthly basis. A process evaluation will be conducted at the end of the pilot study to evaluate the acceptability and engagement with the CLUBMEDS strategy. To date, 104 patients were recruited and grouped into nine clubs, in which patients will be followed-up for 6 months. ETHICS AND DISSEMINATION: The study was approved by the University of Abuja Teaching Hospital and the Federal Teaching Hospital Abakaliki Human Research Ethics Committees and all patients provided informed consent. Our findings will provide preliminary data on the potential effectiveness and acceptance of this strategy in a hypertension context. Study findings will be disseminated via scientific forums.

Current Status and Future Directions of mHealth Interventions for Health System Strengthening in India: Systematic Review.

BACKGROUND: With the exponential increase in mobile phone users in India, a large number of public health initiatives are leveraging information technology and mobile devices for health care delivery. Given the considerable financial and human resources being invested in these initiatives, it is important to ascertain their role in strengthening health care systems. OBJECTIVE: We undertook this review to identify the published mobile health (mHealth) or telemedicine initiatives in India in terms of their current role in health systems strengthening. The review classifies these initiatives based on the disease areas, geographical distribution, and target users and assesses the quality of the available literature. METHODS: A search of the literature was done to identify mHealth or telemedicine articles published between January 1997 and June 2017 from India. The electronic bibliographic databases and registries searched included MEDLINE, EMBASE, Joanna Briggs Institute Database, and Clinical Trial Registry of India. The World Health Organization health system building block framework was used to categorize the published initiatives as per their role in the health system. Quality assessment of the selected articles was done using the Cochrane risk of bias assessment and National Institutes of Health, US tools. RESULTS: The combined search strategies yielded 2150 citations out of which 318 articles were included (primary research articles=125; reviews and system architectural, case studies, and opinion articles=193). A sharp increase was seen after 2012, driven primarily by noncommunicable disease-focused articles. Majority of the primary studies had their sites in the south Indian states, with no published articles from Jammu and Kashmir and north-eastern parts of India. Service delivery was the primary focus of 57.6% (72/125) of the selected articles. A majority of these articles had their focus on 1 (36.0%, 45/125) or 2 (45.6%, 57/125) domains of health system, most frequently service delivery and health workforce. Initiatives commonly used client education as a tool for improving the health system. More than 91.2% (114/125) of the studies, which lacked a sample size justification, had used convenience sampling. Methodological rigor of the selected trials (n=11) was assessed to be poor as majority of the studies had a high risk for bias in at least 2 categories. CONCLUSIONS: In conclusion, mHealth initiatives are being increasingly tested to improve health care delivery in India. Our review highlights the poor quality of the current evidence base and an urgent need for focused research aimed at generating high-quality evidence on the efficacy, user acceptability, and cost-effectiveness of mHealth interventions aimed toward health systems strengthening. A pragmatic approach would be to include an implementation research component into the existing and proposed digital health initiatives to support the generation of evidence for health systems strengthening on strategically important outcomes.

Health system preparedness in noncommunicable diseases: Findings from two states Odisha and Kerala in India.

INTRODUCTION: "Non-communicable diseases (NCDs) are the raging reality of today's world and have moved up the priority list of most countries worldwide including India. The government of India has launched programs such as National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular disease, and Stroke, but little is known about preparedness of health system to address NCDs. METHODS: A qualitative study was conducted in the states of Odisha and Kerala to document the government stakeholder perspectives of health system preparedness for NCDs. RESULTS: The study revealed that both the states have a NCD preparedness structure but need strengthening at various levels. The present human resource is inadequate, over-burdened, and requires specific skills. The lack of workforce adversely affects the service delivery mechanism. The study highlighted that there is a gap in the timely release of funds and also lack of evidence-based application if the information that is made available. CONCLUSION: There is a clear need to fill the gaps and strengthen the identified areas at various levels to address the increasing NCD burden. There is also a need to more in-depth and large-scale studies on such issues which act as external monitoring mechanisms thereby assisting the policy makers and program managers in with relevant and scientific evidence to bring reforms in the health system.

A quasi-experimental intervention to assess the effectiveness of a physician-delivered tobacco cessation intervention in India: A detailed study protocol.

INTRODUCTION: Tobacco cessation is the most important, cost-effective preventive maintenance that clinicians can offer study participants who use tobacco. There is lack of preparedness among primary care physicians in delivering cessation interventions. There are also limited studies which record the effectiveness of cessation interventions in the Indian context. This study is designed to evaluate the effectiveness of brief and intensive tobacco cessation interventions delivered by trained primary care providers in two states of India. METHODS AND ANALYSIS: A quasi-experimental study design has been adopted for the study with around 20 primary care practices, selected from four districts of two states in India (Odisha and Rajasthan). Brief (3A) and Intensive tobacco (5A) cessation intervention services will be provided to two groups of tobacco users, respectively. Both groups will be followed up for 6 months to determine the effectiveness of the cessation interventions. The cost-effectiveness of the services will also be documented at the end of the study. The entire study will be completed in 24 months, of which the final 6 months will be reserved for study participant follow-up and quit rate evaluation. When comparing the two groups, differences between proportions will be assessed by chi-square test and differences between means with t-test. The conventional significance level of 0.05 will be used in all analyses in order to reject the null hypothesis of no difference between groups. We will use difference-in-differences methods to assess the impact of the interventions on physicians' behavior to deliver tobacco cessation in their clinical practice. CONCLUSION: The study is in participant recruitment phase.

Examining Implementation of Tobacco Control Policy at the District Level: A Case Study Analysis from a High Burden State in India.

Introduction. While extensive scientific evidence exists on the tobacco epidemic, a lack of understanding of both policies and their appropriate way of implementation continues to hinder effective tobacco control. This is especially so in the developing countries such as India. The present study aims to understand current implementation practices and the challenges faced in mainstreaming tobacco control policy and program. Methods. We chose a qualitative study design to conduct the case analysis. A total of 42 in-depth interviews were undertaken with seven district officials in six districts of Andhra Pradesh. A conceptual framework was developed by applying grounded theory for analysis. Analysis was undertaken using case analysis approach. Results and Discussion. Our study revealed that most program managers were unfamiliar with the comprehensive tobacco control policy. Respondents have an ambiguous opinion regarding integration of tobacco control program into existing health and development programs. Respondents perceive lack of resources, low prioritization of tobacco control, and lack of monitoring and evaluation of smoke-free laws as limiting factors affecting implementation of tobacco control policy. Conclusion. The findings of this study highlighted the need for a systematic, organized action plan for effective implementation of tobacco control policy and program.

A Delphi study for setting up tobacco research and practice network in India.

BACKGROUND: There are key gaps in the production and dissemination of evidence-based tobacco control research in developing countries. In India, limited research has been made to address and understand the function, constitution, thematic areas of research of a research and practice network in tobacco control. This study aimed to identify priority areas that were agreed by stakeholders for building tobacco research and practice network in India. METHODS: This study used the well-established Delphi survey, which involves asking experts a recurring progression of questions through a series of questionnaires. The study was conducted in two rounds in the year 2013-14. Experts working in tobacco control participated in the study. In Round II, respondents rated agreement using a five-point Likert scale. Interquartile Range (IQR) was used to calculate the strength of the consensus. RESULTS: Experts expressed strong consensus on tobacco cessation and economic research as a focus areas for tobacco research network in India. Lack of funding was stated as a barrier impeding formation of tobacco research network in India by majority of respondents. A strong consensus was achieved on the fact that network can be sustained financially by Government funds (IQR = 1). Information sharing and capacity building of young researchers were the two major benefits as stated by respondents which achieved strong consensus. CONCLUSIONS: This study produced the first national stakeholder-informed priority area for developing tobacco research and practice network in India. The consensus priorities highlight the most important and urgent needs in developing research and practice network in tobacco control.

Preparedness of frontline health workers for tobacco cessation: An exploratory study from two states of India.

BACKGROUND: The 5As approach is a clinic-based approach and has been developed for primary health care providers who are uniquely positioned to interact with tobacco users. The 5As stands for: Ask about tobacco use at every visit, advise tobacco users to quit, assess readiness to quit, assist quit attempts through counseling and pharmacotherapy and arrange follow-up to prevent relapse. The present study explores whether auxiliary nurse midwives (ANMs) adhere to the 3As from the recommended 5As model for tobacco cessation. MATERIALS AND METHODS: The study was a cross-sectional study conducted among 501 ANMs in the state of Gujarat and Andhra Pradesh. Descriptive analysis and chi-square test were employed to test the differences in knowledge levels and practices of ANMs. Bivariate logistic regression was used to examine the association between each predictor variable separately and the outcome variables after adjusting for age and location. Data was analyzed using SPSS version 17 software. RESULTS: Majority of ANMs reported that they were aware of respiratory illnesses, tuberculosis, lung and oral cancer as conditions caused due to tobacco consumption. Awareness of adverse reproductive and child health effects associated with tobacco use was very low. Only about one third of respondents informed all patients about harmful effects. Only 16% of ANMs reported having ever received any on-job training related to tobacco control. ANMs who reported receiving training in tobacco control were about two times more likely to provide information on health effects of tobacco as compared to those who reported not being trained in tobacco control in the state of Gujarat. CONCLUSIONS: A majority of ANMs ask patients about tobacco use but provide advice only to patients suffering from specific diseases. A context-specific capacity building package needs to be designed to equip ANMs in recommended 5As approach in tobacco cessation.