Scaling up a tobacco control intervention in low resource settings: a case example for school teachers in India

Scaling up a tobacco control intervention in low resource settings: a case example for school... Abstract Research on processes of bringing effective tobacco control interventions to scale to increase quit rates among tobacco users is uncommon. This study examines processes to bring to scale one such intervention for school teachers, i.e. Tobacco Free Teacher–Tobacco Free Society (TFT–TFS). This intervention provides a foundation for an effective and low cost approach to promote cessation through schools. The present study was conducted in the states of Bihar and Maharashtra in 2014 using quantitative and qualitative methods. Focus group discussions (FGDs) were analysed using immersion crystallization method. The data presented are from a survey of 291 principals and seven FGDs. This study examined characteristics of principals and teachers, organizational environment, external environmental factors and program characteristics to determine facilitators and barriers for successful dissemination and implementation of the TFT–TFS program. Some facilitators were, incorporation of the program in existing channels like staff meetings and trainings, certification and recognition by the department of education; while some barriers were routine time bound duties (mainly teaching) of teachers and prevalence of tobacco use among teachers and administrators. Principals and teachers expressed a need and high level of interest in the adoption and implementation of the TFT–TFS program in their schools. Introduction Tobacco use kills more than 7 million people annually worldwide. More than six million of those deaths are the result of direct tobacco use, while, around 890,000 are the result of non-smokers being exposed to second-hand smoke. In the 20th century, 100 million tobacco deaths occurred; nearly 70% were in high-income countries [1]. In contrast, in the 21st century, tobacco is expected to kill about one billion people, mostly in low- and middle-income countries. The proportion of deaths attributed to tobacco use is rising rapidly in developing countries [2]. This is particularly important in India, where a large proportion of premature deaths, mainly due to tuberculosis and non-communicable diseases (NCDs), are caused by the use of tobacco in a variety of smoking and smokeless forms [3, 4]. In India, every year, 0.9 million persons are estimated to die prematurely due to smoking [5] and 0.35 million from smokeless tobacco use [6]. Although India was an early signatory to the Framework Convention on Tobacco Control, few resources are available to support tobacco use cessation [7–15]. Most smokers who quit often quit without assistance. If appropriate cessation interventions were made available, this may further increase quit rates [16]. With the increasing understanding of the public health impact of tobacco, there is a need for broad implementation of effective tobacco control interventions that promote tobacco use cessation and establish a social supportive environment [16]. Research on the processes of bringing such effective tobacco control interventions to scale has been sparse, and there is insufficient evidence to determine the most effective ways to promote tobacco cessation in low resource settings. Although few prior studies have paid attention to school teachers’ tobacco use, other school-based studies aimed at tobacco use prevention among students have examined factors contributing to broad-based implementation. For example, one study from India designed for students described how the evidence-based practices from two school-based tobacco control interventions were used to scale up these interventions at the national level across India [17]. Advocacy efforts were pursued through multiple channels, including assisting the government to develop evidence-based guidelines for school health programs. The study highlighted the importance of producing locally relevant research evidence and using strategic and sustained advocacy to translate research into practice that can be supported by the government. Similarly, dissemination/implementation research in the USA has explored factors contributing to scaling up successful programs. Similar to the Indian study, a randomized controlled trial from the USA tested a tobacco control program designed to reduce tobacco use among youth. When the program was proven to be effective, the study team identified key stakeholders who had important roles in program diffusion, adoption and maintenance. They found that school personnel, Department of Education (DoE) and other organizations with experience in national dissemination are crucial for effective dissemination of the program [18]. Based on these findings, nationally standardized protocols for program delivery, research and evaluation were developed. School teachers in India are an important resource for promoting tobacco control in schools and in society at large, given their roles as community leaders and role models. However, tobacco use among teachers is high: The Global School Personnel Survey, conducted in 2000, found that 78% of teachers in Bihar used some form of tobacco [19]. A tobacco use cessation intervention for school teachers called Tobacco Free Teachers–Tobacco Free Society (TFT–TFS), which included educational efforts, tobacco control policies and cessation support, was tested in a cluster randomized controlled trial in the Bihar School Teachers’ Study. This intervention was found to be effective in increasing tobacco use cessation among school teachers [20]. The TFT–TFS intervention was designed in response to the local social context and aimed to build on the social resources among teachers, who can help shape social norms and serve as role models for tobacco control in their communities. In the TFT–TFS intervention, a lead teacher was designated by the school principal to work with the project. These lead teachers were trained by project staff in the TFT–TFS program and the basics of tobacco control. Project health educators worked with a lead teacher in each school to deliver the program to all teachers. Immediately post-intervention, the 30-day quit rate was 50% in the intervention schools compared with 15% in the control schools; 9 months after the completion of the intervention, the 6-months quit rate was 19% in the intervention schools and 7% in the control schools [20]. This research thus provides the foundation for an effective intervention to promote cessation among school teachers in low-resource settings. The next logical step to put this research into practice was to develop and test strategies for delivering such interventions at a larger scale. Therefore, this pilot study was designed to better understand the gap between implementation and dissemination, and possible ways to accelerate the pace of dissemination of this type of tobacco control intervention in low resource settings [7, 21–22]. The Social Contextual Model (SCM) of Health Behaviour Change was used as a theoretical framework [23] to guide the organization of factors related to the perception of principals and potential lead teachers for implementing the TFT–TFS program. The overall objective of this pilot study was to generate an in-depth understanding of the factors associated with schools’ capability and willingness to adopt a comprehensive tobacco control program that will support cessation among school teachers. The specific aims of the study were to: (i) determine schools’ willingness to adopt a comprehensive tobacco use cessation intervention for teachers; (ii) describe the characteristics of organizations, school principals and the broader environment associated with schools’ willingness to adopt such programs and (iii) describe the perceptions of school principals and potential lead teachers of the feasibility and acceptability of implementing the TFT–TFS program, including identifying the need for any program adaptations. Materials and methods Study population This pilot study was conducted in the states of Bihar and Maharashtra in 2014. These two states were specifically selected considering the diversity of settings within India. In Bihar, resources are scarce, the supporting infrastructure thin, and prevalence of tobacco higher (53.5%) compared with Maharashtra (31.4%) [24]. This diversity was chosen to provide a broad-based understanding of the factors that may influence schools’ decisions to adopt tobacco control programs, which can enhance generalizability to other areas in India and elsewhere. This study included school principals and teachers of government and government-aided schools from rural and urban areas of Bihar and Maharashtra. Lists of 3909 eligible schools in 34 districts of Maharashtra and 1076 eligible schools in 10 districts of Bihar having grades 8–10 were obtained. These lists included the names and phone numbers of teachers and principals. Schools were identified through their districts (highest school administrative unit), and clusters (lowest school administrative unit), wherein a cluster was a sub-unit of the block and the block was a sub-unit of school districts in India. All schools having grades 8–10 and at least eight teachers were eligible to participate in the study. In Bihar, schools that participated in the BSTS were excluded from the eligible sample. Data collection methods The pilot study involved data collection through both quantitative and qualitative methods: (i) telephone surveys with principals of randomly selected schools; and (ii) focus groups with principals and potential lead teachers identified by schools’ principals. A structured survey instrument was used to conduct telephone interviews with 150 principals in each state. A verbal informed consent from principals was obtained. Telephone interviews were administered by trained survey administrators in Hindi and Marathi. Response rates were enhanced by making call attempts at various times of the day and week; and scheduling specific times to call back at the convenience of each respondent. For focus group discussions (FGDs), principals were invited to attend, and were asked to identify and invite a teacher from their school who would potentially play the role of a lead teacher. Schools participated in telephone interviews were excluded from FGDs to ensure their responses in the FGDs were not influenced by their participation in the survey. FGDs were conducted at a centralized location within each state, and were conducted by trained moderators who were involved in BSTS. FGDs were conducted in local languages in the respective states (Hindi in Bihar, Marathi in Maharashtra), transcribed, and translated into English. A total of seven focus groups were conducted in Bihar represented by 10 rural and 6 urban schools and in Maharashtra represented by 43 rural and 27 urban schools. Among these, three (one in Bihar and two in Maharashtra) FGDs were conducted with principals (n = 47) and four (two in each state) with potential lead teachers (n = 86) identified by respective school principals. About 15 participants were included in each FGD. An independent team of one moderator and one note taker were involved in each state. Measures The survey assessed individual characteristics of the principals (i.e. demographics, tobacco use history, self-efficacy, attitude towards and motivation to adopt tobacco control programs and policies) [25–26]; organizational characteristics of their schools (e.g. collective efficacy, organizational climate to adopt tobacco control programs and policies, shared sense of program goals and vision) [25, 27–29]; and characteristics of the school district or block (i.e. district/block demographics, relationship with DoE). Standard measures available in the literature, including the authors’ previous works, like utilizing the SCM [23] of Health Behaviour Change as a theoretical framework for examining association between social environment and tobacco use among teachers, were adapted for this study. For the qualitative data, an open-ended moderator guide was developed in which questions to be asked were specified. Moderators were allowed the flexibility to add fresh questions and to probe on relevant areas more fully, thus capitalizing on the strength of this technique. Questions explored perceptions of and reactions to the TFT–TFS program materials and approaches; applicability of these materials and approaches within their settings; factors and organizations most influential in decision-making regarding program offerings; barriers to and facilitators of adopting the TFT–TFS program materials and approaches; resources available to implement the program in schools; feasibility of the lead teacher roles including best ways to support their ongoing engagement; adaptations needed for them for the program; and optimal ways to promote it to school principals. Data analysis In order to recruit a pre-defined sample of 150 principals in each state to conduct telephone interviews, 402 principals in Bihar and 254 principals in Maharashtra were approached. Some 62% of principals in Bihar and 41% of principles in Maharashtra could not be recruited due to bad telephone numbers and 1% principals in Bihar refused to participate. Among the 300 surveyed school principals, nine principals answered ‘no’ to the question, ‘Are you interested in adopting the program in your school?’ Of these nine, two were from Bihar and seven were from Maharashtra. Out of these nine, only one principal from Maharashtra reported using tobacco. The most common reason for their non-interest was their unavailability including being busy with their academic work at the time this study was conducted. Thus, the survey analysis was restricted to 291 principals who reported their interest in adopting the program in their schools. Analysis of the survey data involved descriptive statistics of the school’s characteristics, perceptions about the value of tobacco control interventions, and willingness to adopt such programs. Point estimates were calculated with 95% confidence intervals for all measures (percentages), separately for the two states. Focus group discussions were analysed using immersion-crystallization method [30], which allowed the authors to conduct concentrated reviews of the data, to reflect upon them, and formulate independent interpretations before collectively agreeing upon the major ideas. Initial content analysis was done and broad recurring themes were identified by co-authors located in Mumbai, India. All verbatim quotes from the transcripts were recorded as stated by the respondents to prevent any loss of interpretation. The themes document was then shared with co-authors in Boston who independently reviewed, reflected upon and conducted their own data analysis. The investigators then ‘crystallized’ the diverse interpretations of the data until a final interpretation emerged. The results include key themes emerging (related to school personnel’s views about feasibility of adoption of program, potential facilitators and barriers and ways to integrate the program in existing system) which either supported or augmented the findings from the analyses of quantitative data. Ethical consideration Study methods and materials were approved by institutional review boards at the Harvard T. H. Chan School of Public Health in the United States and the Healis-Sekhsaria Institute for Public Health in India. The study protocol was reviewed and cleared by the Indian Council of Medical Research. Verbal informed consent was obtained for all data collection activities after assuring anonymity, and appropriate strategies for protecting study participants from any risks related to the research, including loss of confidentiality, were carefully followed. Results Survey results Respondent and school characteristics Out of 291 principals (Table I), most principals were men, 51 years of age or older, and had been a principal for over 20 years. Around 10% of principals from both states reported using of tobacco during the last 30 days. Regarding characteristics of the schools (Table II), 7.4% of schools in Bihar and 38.7% in Maharashtra reported having a written tobacco control policy. Fewer than 35% of principals from both states reported that tobacco education was provided to their teachers, while almost all principals from both states reported that tobacco education was provided to their students. Almost all principals from both states reported receiving curriculum training, mostly at the highest school administrative unit (i.e. district 98.6%) in Bihar and at every school administrative unit (i.e. the district 52.1%, cluster 61.7% and block 68.3%) in Maharashtra. There were large differences between the states in principals’ reporting that their teachers received other professional development trainings (in Bihar, 7.5%, and in Maharashtra, 61.5%). More than half of the principals reported that their teachers would be likely to spare time for non-teaching activities (in Maharashtra, 87.2%, and in Bihar, 54.7%). Table I. Characteristics of principals in Maharashtra and Bihar Demographics of principals and their perceptions about feasibility of adopting program Interested (N = 291) Maharashtra (n = 143) Bihar (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Characteristics of principals Sex Female 31 21.7 (15.7, 29.1) 34 23 (16.9, 30.4) Male 112 78.3 (70.9, 84.3) 114 77 (69.6, 83.1) Age of principal ≤40 6 4.6 (2.1, 9.6) 6 4.1 (1.9, 8.6) 41–50 32 24.4 (17.9, 32.5) 21 14.2 (9.5, 20.7) >50 93 71 (62.7, 78.1) 121 81.8 (74.8, 87.2) No. of years principal in education service ≤10 5 3.5 (1.5, 7.9) 17 11.5 (7.3, 17.6) 11–20 25 17.5 (12.1, 24.5) 8 5.4 (2.8, 10.3) 21–30 79 55.2 (47.1, 63.2) 55 37.2 (29.8, 45.2) >30 34 23.8 (17.6, 31.4) 68 45.9 (38.1, 54.0) No of years principal of this school 1 year 46 32.2 (25.1, 40.2) 51 34.5 (27.3, 42.4) 2–5 years 72 50.4 (42.3, 58.4) 67 45.3 (37.5, 53.3) >5 years 25 17.5 (12.1, 24.5) 30 20.3 (14.6, 27.5) Tobacco used in last 30 days Yes 14 10.1 (6.1, 16.2) 19 13 (8.5, 19.4) Demographics of principals and their perceptions about feasibility of adopting program Interested (N = 291) Maharashtra (n = 143) Bihar (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Characteristics of principals Sex Female 31 21.7 (15.7, 29.1) 34 23 (16.9, 30.4) Male 112 78.3 (70.9, 84.3) 114 77 (69.6, 83.1) Age of principal ≤40 6 4.6 (2.1, 9.6) 6 4.1 (1.9, 8.6) 41–50 32 24.4 (17.9, 32.5) 21 14.2 (9.5, 20.7) >50 93 71 (62.7, 78.1) 121 81.8 (74.8, 87.2) No. of years principal in education service ≤10 5 3.5 (1.5, 7.9) 17 11.5 (7.3, 17.6) 11–20 25 17.5 (12.1, 24.5) 8 5.4 (2.8, 10.3) 21–30 79 55.2 (47.1, 63.2) 55 37.2 (29.8, 45.2) >30 34 23.8 (17.6, 31.4) 68 45.9 (38.1, 54.0) No of years principal of this school 1 year 46 32.2 (25.1, 40.2) 51 34.5 (27.3, 42.4) 2–5 years 72 50.4 (42.3, 58.4) 67 45.3 (37.5, 53.3) >5 years 25 17.5 (12.1, 24.5) 30 20.3 (14.6, 27.5) Tobacco used in last 30 days Yes 14 10.1 (6.1, 16.2) 19 13 (8.5, 19.4) Table I. Characteristics of principals in Maharashtra and Bihar Demographics of principals and their perceptions about feasibility of adopting program Interested (N = 291) Maharashtra (n = 143) Bihar (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Characteristics of principals Sex Female 31 21.7 (15.7, 29.1) 34 23 (16.9, 30.4) Male 112 78.3 (70.9, 84.3) 114 77 (69.6, 83.1) Age of principal ≤40 6 4.6 (2.1, 9.6) 6 4.1 (1.9, 8.6) 41–50 32 24.4 (17.9, 32.5) 21 14.2 (9.5, 20.7) >50 93 71 (62.7, 78.1) 121 81.8 (74.8, 87.2) No. of years principal in education service ≤10 5 3.5 (1.5, 7.9) 17 11.5 (7.3, 17.6) 11–20 25 17.5 (12.1, 24.5) 8 5.4 (2.8, 10.3) 21–30 79 55.2 (47.1, 63.2) 55 37.2 (29.8, 45.2) >30 34 23.8 (17.6, 31.4) 68 45.9 (38.1, 54.0) No of years principal of this school 1 year 46 32.2 (25.1, 40.2) 51 34.5 (27.3, 42.4) 2–5 years 72 50.4 (42.3, 58.4) 67 45.3 (37.5, 53.3) >5 years 25 17.5 (12.1, 24.5) 30 20.3 (14.6, 27.5) Tobacco used in last 30 days Yes 14 10.1 (6.1, 16.2) 19 13 (8.5, 19.4) Demographics of principals and their perceptions about feasibility of adopting program Interested (N = 291) Maharashtra (n = 143) Bihar (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Characteristics of principals Sex Female 31 21.7 (15.7, 29.1) 34 23 (16.9, 30.4) Male 112 78.3 (70.9, 84.3) 114 77 (69.6, 83.1) Age of principal ≤40 6 4.6 (2.1, 9.6) 6 4.1 (1.9, 8.6) 41–50 32 24.4 (17.9, 32.5) 21 14.2 (9.5, 20.7) >50 93 71 (62.7, 78.1) 121 81.8 (74.8, 87.2) No. of years principal in education service ≤10 5 3.5 (1.5, 7.9) 17 11.5 (7.3, 17.6) 11–20 25 17.5 (12.1, 24.5) 8 5.4 (2.8, 10.3) 21–30 79 55.2 (47.1, 63.2) 55 37.2 (29.8, 45.2) >30 34 23.8 (17.6, 31.4) 68 45.9 (38.1, 54.0) No of years principal of this school 1 year 46 32.2 (25.1, 40.2) 51 34.5 (27.3, 42.4) 2–5 years 72 50.4 (42.3, 58.4) 67 45.3 (37.5, 53.3) >5 years 25 17.5 (12.1, 24.5) 30 20.3 (14.6, 27.5) Tobacco used in last 30 days Yes 14 10.1 (6.1, 16.2) 19 13 (8.5, 19.4) Table II. Characteristics of schools, stratified by state School demographics and other characteristics Interested (N = 291) Maharashtra (n = 143) Bihar (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Characteristics of schools Schools have a written tobacco policy Yes 55 38.7 (31.1, 46.9) 11 7.4 (4.2, 12.8) Tobacco education is provided to teachers Yes 48 34 (26.7, 42.2) 31 20.9 (15.2, 28.2) Tobacco education is taught to students Yes 115 81 (73.8, 86.6) 139 93.9 (88.9, 96.8) Teachers’ time for non-teaching activities per week beyond teaching students No Time 18 12.8 (8.2, 19.3) 67 45.3 (37.5, 53.3) <1 h 79 56 (47.8, 64.0) 27 18.2 (12.9, 25.2) 1–2 h 31 22 (16.0, 29.5) 45 30.4 (23.6, 38.2) >3 h 13 9.3 (5.4, 15.1) 9 6.1 (3.2, 11.2) School location Rural 66 46.2 (38.2, 54.3) 112 75.7 (68.2, 81.9) Supportive environment at cluster, block and district level for program implementation How often do you have contact with trainers from the Department of Education outside school at the district level? Weekly 19 13.4 (8.7, 20.0) 0 0 — Monthly 55 38.7 (31.1, 46.9) 146 98.6 (95.2, 99.6) Quarterly 33 23.2 (17.1, 30.8) 0 0 — Bi-annually 16 11.3 (7.1, 17.5) 0 0 — Annually 17 12 (7.6, 18.3) 0 0 — Never 2 1.4 (0.4, 5.0) 1 0.7 (0.1, 3.7) Not applicable 0 0 — 1 0.7 (0.1, 3.7) How often do you have contact with trainers from the Department of Education outside school at the block level? Weekly 38 26.8 (20.2, 34.6) 0 0 — Monthly 59 41.5 (33.8, 49.8) 0 0 — Quarterly 28 19.7 (14.0, 27.0) 0 0 — Bi-annually 10 7 (3.9, 12.5) 0 0 — Annually 5 3.5 (1.5, 8.0) 1 0.7 (0.1, 3.7) Never 2 1.4 (0.4, 5.0) 2 1.4 (0.4, 4.8) Not applicable 0 0 — 145 98 (94.2, 99.3) How often do you have contact with trainers from the Department of Education outside school at the cluster level? Weekly 39 27.7 (20.9, 35.6) 0 0 — Monthly 48 34 (26.7, 42.2) 1 0.7 (0.1, 3.7) Quarterly 29 20.6 (14.7, 28.0) 1 0.7 (0.1, 3.7) Bi-annually 11 7.8 (4.4, 13.4) 0 0 — Annually 12 8.5 (4.9, 14.3) 0 0 — Never 2 1.4 (0.4, 5.0) 1 0.7 (0.1, 3.7) Not applicable 0 0 — 145 98 (94.2, 99.3) Receipt of other trainings/programs Teachers receive curriculum training Yes 143 100 (97.4, 100) 135 91.8 (86.3, 95.3) Teachers receive other professional development training Yes 88 61.5 (53.4, 69.1) 11 7.5 (4.2, 12.9) In the last 2 years, teachers have been offered any health or wellness programs Yes 54 37.8 (30.2, 45.9) 16 10.8 (6.8, 16.8) School demographics and other characteristics Interested (N = 291) Maharashtra (n = 143) Bihar (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Characteristics of schools Schools have a written tobacco policy Yes 55 38.7 (31.1, 46.9) 11 7.4 (4.2, 12.8) Tobacco education is provided to teachers Yes 48 34 (26.7, 42.2) 31 20.9 (15.2, 28.2) Tobacco education is taught to students Yes 115 81 (73.8, 86.6) 139 93.9 (88.9, 96.8) Teachers’ time for non-teaching activities per week beyond teaching students No Time 18 12.8 (8.2, 19.3) 67 45.3 (37.5, 53.3) <1 h 79 56 (47.8, 64.0) 27 18.2 (12.9, 25.2) 1–2 h 31 22 (16.0, 29.5) 45 30.4 (23.6, 38.2) >3 h 13 9.3 (5.4, 15.1) 9 6.1 (3.2, 11.2) School location Rural 66 46.2 (38.2, 54.3) 112 75.7 (68.2, 81.9) Supportive environment at cluster, block and district level for program implementation How often do you have contact with trainers from the Department of Education outside school at the district level? Weekly 19 13.4 (8.7, 20.0) 0 0 — Monthly 55 38.7 (31.1, 46.9) 146 98.6 (95.2, 99.6) Quarterly 33 23.2 (17.1, 30.8) 0 0 — Bi-annually 16 11.3 (7.1, 17.5) 0 0 — Annually 17 12 (7.6, 18.3) 0 0 — Never 2 1.4 (0.4, 5.0) 1 0.7 (0.1, 3.7) Not applicable 0 0 — 1 0.7 (0.1, 3.7) How often do you have contact with trainers from the Department of Education outside school at the block level? Weekly 38 26.8 (20.2, 34.6) 0 0 — Monthly 59 41.5 (33.8, 49.8) 0 0 — Quarterly 28 19.7 (14.0, 27.0) 0 0 — Bi-annually 10 7 (3.9, 12.5) 0 0 — Annually 5 3.5 (1.5, 8.0) 1 0.7 (0.1, 3.7) Never 2 1.4 (0.4, 5.0) 2 1.4 (0.4, 4.8) Not applicable 0 0 — 145 98 (94.2, 99.3) How often do you have contact with trainers from the Department of Education outside school at the cluster level? Weekly 39 27.7 (20.9, 35.6) 0 0 — Monthly 48 34 (26.7, 42.2) 1 0.7 (0.1, 3.7) Quarterly 29 20.6 (14.7, 28.0) 1 0.7 (0.1, 3.7) Bi-annually 11 7.8 (4.4, 13.4) 0 0 — Annually 12 8.5 (4.9, 14.3) 0 0 — Never 2 1.4 (0.4, 5.0) 1 0.7 (0.1, 3.7) Not applicable 0 0 — 145 98 (94.2, 99.3) Receipt of other trainings/programs Teachers receive curriculum training Yes 143 100 (97.4, 100) 135 91.8 (86.3, 95.3) Teachers receive other professional development training Yes 88 61.5 (53.4, 69.1) 11 7.5 (4.2, 12.9) In the last 2 years, teachers have been offered any health or wellness programs Yes 54 37.8 (30.2, 45.9) 16 10.8 (6.8, 16.8) Table II. Characteristics of schools, stratified by state School demographics and other characteristics Interested (N = 291) Maharashtra (n = 143) Bihar (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Characteristics of schools Schools have a written tobacco policy Yes 55 38.7 (31.1, 46.9) 11 7.4 (4.2, 12.8) Tobacco education is provided to teachers Yes 48 34 (26.7, 42.2) 31 20.9 (15.2, 28.2) Tobacco education is taught to students Yes 115 81 (73.8, 86.6) 139 93.9 (88.9, 96.8) Teachers’ time for non-teaching activities per week beyond teaching students No Time 18 12.8 (8.2, 19.3) 67 45.3 (37.5, 53.3) <1 h 79 56 (47.8, 64.0) 27 18.2 (12.9, 25.2) 1–2 h 31 22 (16.0, 29.5) 45 30.4 (23.6, 38.2) >3 h 13 9.3 (5.4, 15.1) 9 6.1 (3.2, 11.2) School location Rural 66 46.2 (38.2, 54.3) 112 75.7 (68.2, 81.9) Supportive environment at cluster, block and district level for program implementation How often do you have contact with trainers from the Department of Education outside school at the district level? Weekly 19 13.4 (8.7, 20.0) 0 0 — Monthly 55 38.7 (31.1, 46.9) 146 98.6 (95.2, 99.6) Quarterly 33 23.2 (17.1, 30.8) 0 0 — Bi-annually 16 11.3 (7.1, 17.5) 0 0 — Annually 17 12 (7.6, 18.3) 0 0 — Never 2 1.4 (0.4, 5.0) 1 0.7 (0.1, 3.7) Not applicable 0 0 — 1 0.7 (0.1, 3.7) How often do you have contact with trainers from the Department of Education outside school at the block level? Weekly 38 26.8 (20.2, 34.6) 0 0 — Monthly 59 41.5 (33.8, 49.8) 0 0 — Quarterly 28 19.7 (14.0, 27.0) 0 0 — Bi-annually 10 7 (3.9, 12.5) 0 0 — Annually 5 3.5 (1.5, 8.0) 1 0.7 (0.1, 3.7) Never 2 1.4 (0.4, 5.0) 2 1.4 (0.4, 4.8) Not applicable 0 0 — 145 98 (94.2, 99.3) How often do you have contact with trainers from the Department of Education outside school at the cluster level? Weekly 39 27.7 (20.9, 35.6) 0 0 — Monthly 48 34 (26.7, 42.2) 1 0.7 (0.1, 3.7) Quarterly 29 20.6 (14.7, 28.0) 1 0.7 (0.1, 3.7) Bi-annually 11 7.8 (4.4, 13.4) 0 0 — Annually 12 8.5 (4.9, 14.3) 0 0 — Never 2 1.4 (0.4, 5.0) 1 0.7 (0.1, 3.7) Not applicable 0 0 — 145 98 (94.2, 99.3) Receipt of other trainings/programs Teachers receive curriculum training Yes 143 100 (97.4, 100) 135 91.8 (86.3, 95.3) Teachers receive other professional development training Yes 88 61.5 (53.4, 69.1) 11 7.5 (4.2, 12.9) In the last 2 years, teachers have been offered any health or wellness programs Yes 54 37.8 (30.2, 45.9) 16 10.8 (6.8, 16.8) School demographics and other characteristics Interested (N = 291) Maharashtra (n = 143) Bihar (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Characteristics of schools Schools have a written tobacco policy Yes 55 38.7 (31.1, 46.9) 11 7.4 (4.2, 12.8) Tobacco education is provided to teachers Yes 48 34 (26.7, 42.2) 31 20.9 (15.2, 28.2) Tobacco education is taught to students Yes 115 81 (73.8, 86.6) 139 93.9 (88.9, 96.8) Teachers’ time for non-teaching activities per week beyond teaching students No Time 18 12.8 (8.2, 19.3) 67 45.3 (37.5, 53.3) <1 h 79 56 (47.8, 64.0) 27 18.2 (12.9, 25.2) 1–2 h 31 22 (16.0, 29.5) 45 30.4 (23.6, 38.2) >3 h 13 9.3 (5.4, 15.1) 9 6.1 (3.2, 11.2) School location Rural 66 46.2 (38.2, 54.3) 112 75.7 (68.2, 81.9) Supportive environment at cluster, block and district level for program implementation How often do you have contact with trainers from the Department of Education outside school at the district level? Weekly 19 13.4 (8.7, 20.0) 0 0 — Monthly 55 38.7 (31.1, 46.9) 146 98.6 (95.2, 99.6) Quarterly 33 23.2 (17.1, 30.8) 0 0 — Bi-annually 16 11.3 (7.1, 17.5) 0 0 — Annually 17 12 (7.6, 18.3) 0 0 — Never 2 1.4 (0.4, 5.0) 1 0.7 (0.1, 3.7) Not applicable 0 0 — 1 0.7 (0.1, 3.7) How often do you have contact with trainers from the Department of Education outside school at the block level? Weekly 38 26.8 (20.2, 34.6) 0 0 — Monthly 59 41.5 (33.8, 49.8) 0 0 — Quarterly 28 19.7 (14.0, 27.0) 0 0 — Bi-annually 10 7 (3.9, 12.5) 0 0 — Annually 5 3.5 (1.5, 8.0) 1 0.7 (0.1, 3.7) Never 2 1.4 (0.4, 5.0) 2 1.4 (0.4, 4.8) Not applicable 0 0 — 145 98 (94.2, 99.3) How often do you have contact with trainers from the Department of Education outside school at the cluster level? Weekly 39 27.7 (20.9, 35.6) 0 0 — Monthly 48 34 (26.7, 42.2) 1 0.7 (0.1, 3.7) Quarterly 29 20.6 (14.7, 28.0) 1 0.7 (0.1, 3.7) Bi-annually 11 7.8 (4.4, 13.4) 0 0 — Annually 12 8.5 (4.9, 14.3) 0 0 — Never 2 1.4 (0.4, 5.0) 1 0.7 (0.1, 3.7) Not applicable 0 0 — 145 98 (94.2, 99.3) Receipt of other trainings/programs Teachers receive curriculum training Yes 143 100 (97.4, 100) 135 91.8 (86.3, 95.3) Teachers receive other professional development training Yes 88 61.5 (53.4, 69.1) 11 7.5 (4.2, 12.9) In the last 2 years, teachers have been offered any health or wellness programs Yes 54 37.8 (30.2, 45.9) 16 10.8 (6.8, 16.8) Facilitators and barriers for program implementation There was strong consensus on key facilitators to program adoption/implementation, including providing flexibility to integrate the program into staff meetings; involving parents and community; certifying teacher’s participation in the program and recognition of school by the DoE (see Table III). The recognition by the community was considered as a less important facilitator for principals of Bihar (13.2%) than principals of Maharashtra (90.8%). Table III. Perceptions of principals in Bihar and Maharashtra regarding facilitators and barriers of program implementation Perceptions of principals regarding facilitators and barriers Interested (N = 291) Maharashtra Bihar (n = 143) (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Facilitators to program implementation Flexibility to integrate program into staff meetings or trainings Strongly agree/Agree 130 90.9 (85.1, 94.6) 146 98.6 (95.2, 99.6) Integration of program content into students curriculum Strongly agree/Agree 139 97.9 (94.0, 99.3) 148 100 (97.5, 100.0) Involvement of community and parents in the program Strongly agree/Agree 126 88.1 (81.8, 92.4) 146 98.6 (95.2, 99.6) Program participation certificates for teachers Strongly agree/Agree 141 98.6 (95.0, 99.6) 146 98.6 (95.2, 99.6) Recognition of the school by the Department of Education Strongly agree/Agree 142 99.3 (96.1, 99.9) 140 94.6 (89.7, 97.2) Recognition of the school by the community Strongly agree/Agree 129 90.8 (84.9, 94.6) 20 13.5 (8.9, 19.9) Barriers to program implementation Obligatory duties of teachers Disagree/Strongly Disagree 62 43.4 (35.5, 51.6) 145 98 (94.2, 99.3) Very high prevalence of tobacco use among teachers Disagree/Strongly Disagree 93 79.5 (71.3, 85.8) 139 97.2 (93.0, 98.9) Very low prevalence of tobacco use among teachers Disagree/Strongly Disagree 97 82.9 (75.1, 88.7) 143 99.3 (96.2, 99.9) Tobacco use by decision makers Disagree/Strongly Disagree 92 80 (71.8, 86.3) 142 99.3 (96.1, 99.9) Teachers having health priorities other than tobacco Disagree/Strongly Disagree 94 65.7 (57.6, 73.0) 146 98.6 (95.2, 99.6) Perceptions of principals regarding facilitators and barriers Interested (N = 291) Maharashtra Bihar (n = 143) (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Facilitators to program implementation Flexibility to integrate program into staff meetings or trainings Strongly agree/Agree 130 90.9 (85.1, 94.6) 146 98.6 (95.2, 99.6) Integration of program content into students curriculum Strongly agree/Agree 139 97.9 (94.0, 99.3) 148 100 (97.5, 100.0) Involvement of community and parents in the program Strongly agree/Agree 126 88.1 (81.8, 92.4) 146 98.6 (95.2, 99.6) Program participation certificates for teachers Strongly agree/Agree 141 98.6 (95.0, 99.6) 146 98.6 (95.2, 99.6) Recognition of the school by the Department of Education Strongly agree/Agree 142 99.3 (96.1, 99.9) 140 94.6 (89.7, 97.2) Recognition of the school by the community Strongly agree/Agree 129 90.8 (84.9, 94.6) 20 13.5 (8.9, 19.9) Barriers to program implementation Obligatory duties of teachers Disagree/Strongly Disagree 62 43.4 (35.5, 51.6) 145 98 (94.2, 99.3) Very high prevalence of tobacco use among teachers Disagree/Strongly Disagree 93 79.5 (71.3, 85.8) 139 97.2 (93.0, 98.9) Very low prevalence of tobacco use among teachers Disagree/Strongly Disagree 97 82.9 (75.1, 88.7) 143 99.3 (96.2, 99.9) Tobacco use by decision makers Disagree/Strongly Disagree 92 80 (71.8, 86.3) 142 99.3 (96.1, 99.9) Teachers having health priorities other than tobacco Disagree/Strongly Disagree 94 65.7 (57.6, 73.0) 146 98.6 (95.2, 99.6) Table III. Perceptions of principals in Bihar and Maharashtra regarding facilitators and barriers of program implementation Perceptions of principals regarding facilitators and barriers Interested (N = 291) Maharashtra Bihar (n = 143) (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Facilitators to program implementation Flexibility to integrate program into staff meetings or trainings Strongly agree/Agree 130 90.9 (85.1, 94.6) 146 98.6 (95.2, 99.6) Integration of program content into students curriculum Strongly agree/Agree 139 97.9 (94.0, 99.3) 148 100 (97.5, 100.0) Involvement of community and parents in the program Strongly agree/Agree 126 88.1 (81.8, 92.4) 146 98.6 (95.2, 99.6) Program participation certificates for teachers Strongly agree/Agree 141 98.6 (95.0, 99.6) 146 98.6 (95.2, 99.6) Recognition of the school by the Department of Education Strongly agree/Agree 142 99.3 (96.1, 99.9) 140 94.6 (89.7, 97.2) Recognition of the school by the community Strongly agree/Agree 129 90.8 (84.9, 94.6) 20 13.5 (8.9, 19.9) Barriers to program implementation Obligatory duties of teachers Disagree/Strongly Disagree 62 43.4 (35.5, 51.6) 145 98 (94.2, 99.3) Very high prevalence of tobacco use among teachers Disagree/Strongly Disagree 93 79.5 (71.3, 85.8) 139 97.2 (93.0, 98.9) Very low prevalence of tobacco use among teachers Disagree/Strongly Disagree 97 82.9 (75.1, 88.7) 143 99.3 (96.2, 99.9) Tobacco use by decision makers Disagree/Strongly Disagree 92 80 (71.8, 86.3) 142 99.3 (96.1, 99.9) Teachers having health priorities other than tobacco Disagree/Strongly Disagree 94 65.7 (57.6, 73.0) 146 98.6 (95.2, 99.6) Perceptions of principals regarding facilitators and barriers Interested (N = 291) Maharashtra Bihar (n = 143) (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Facilitators to program implementation Flexibility to integrate program into staff meetings or trainings Strongly agree/Agree 130 90.9 (85.1, 94.6) 146 98.6 (95.2, 99.6) Integration of program content into students curriculum Strongly agree/Agree 139 97.9 (94.0, 99.3) 148 100 (97.5, 100.0) Involvement of community and parents in the program Strongly agree/Agree 126 88.1 (81.8, 92.4) 146 98.6 (95.2, 99.6) Program participation certificates for teachers Strongly agree/Agree 141 98.6 (95.0, 99.6) 146 98.6 (95.2, 99.6) Recognition of the school by the Department of Education Strongly agree/Agree 142 99.3 (96.1, 99.9) 140 94.6 (89.7, 97.2) Recognition of the school by the community Strongly agree/Agree 129 90.8 (84.9, 94.6) 20 13.5 (8.9, 19.9) Barriers to program implementation Obligatory duties of teachers Disagree/Strongly Disagree 62 43.4 (35.5, 51.6) 145 98 (94.2, 99.3) Very high prevalence of tobacco use among teachers Disagree/Strongly Disagree 93 79.5 (71.3, 85.8) 139 97.2 (93.0, 98.9) Very low prevalence of tobacco use among teachers Disagree/Strongly Disagree 97 82.9 (75.1, 88.7) 143 99.3 (96.2, 99.9) Tobacco use by decision makers Disagree/Strongly Disagree 92 80 (71.8, 86.3) 142 99.3 (96.1, 99.9) Teachers having health priorities other than tobacco Disagree/Strongly Disagree 94 65.7 (57.6, 73.0) 146 98.6 (95.2, 99.6) When asked about potential barriers to the program implementation, almost all principals from Bihar disagreed that any specific factor could serve as a barrier. In contrast, principals from Maharashtra felt that factors such as obligatory duties of teachers (56.6%); tobacco use by teachers (19%) or decision-makers (20%); and teachers having other health priorities (34.3%) could serve as barriers in the program adoption/implementation. Principals of Bihar reported higher interest in learning about tobacco control and control of other NCD risk factors than principals of Maharashtra (Fig. 1). However, interest in learning about tobacco control was lower than that of other health topics such as blood pressure management, diabetes screening and obesity prevention. Fig. 1. View largeDownload slide Principals (n = 291) interest in learning about health topics. Fig. 1. View largeDownload slide Principals (n = 291) interest in learning about health topics. Focus group discussion regarding facilitators and barriers of program implementation Several themes related to facilitators and barriers to adoption and implementation of the TFT–TFS program emerged across all focus group discussions. As the findings for both states were mostly similar, only combined findings are presented here. Specific themes emerged and the relevant verbatim quotes are presented below: 1. Teachers and principals expressed a need for a tobacco control program for teachers: Teachers and principals recognized the important role of teachers in the TFT–TFS program, as quoted below. ‘Being an ideal teacher, my behaviour in front of students and society, my status in the society should be good……So, that’s why it is important that I control myself.’ They also acknowledged that some teachers are addicted to tobacco, which was a matter of concern needing a response. ‘In our entire high school the percentage of addiction (to tobacco) is about 10%, because in secondary schools we get jobs very late (mainly because of additional 3 to 5 years of education is required to become eligible to serve as a secondary teacher and hence earning money starts late). So, the percentage of addiction is not very high; but, in primary school, the addiction is highest because after completing 10th (secondary education) or 12th (higher secondary education) they complete D. Ed. (one-year Diploma in Education) and get jobs as primary teacher (start earning money at an early age compared to secondary teachers) and then addiction starts… .’ Because teachers had not received any program related to tobacco control, they were interested in such programs. They mentioned that there were many health programs for students (e.g. on anaemia) and community responsibilities (e.g. collecting census data) that teachers were responsible for implementing. However, the TFT–TFS program was unique because teachers were the focus of the program. Additionally students and communities might also benefit from the program, as quoted below. ‘This tobacco de-addiction program is a very important point (program) that considers the health of teachers; if the teachers have good health then everything will be fine.’ In Bihar, teachers and principals generally reported that there was no tobacco control policy in place at the school level and it was essential to have a policy to reduce tobacco use among teachers. …; but, tobacco has become so worldwide acceptable that one teacher offers tobacco to another teacher even in front of their students.’ In Maharashtra, however, most of the teachers reported that the school tobacco control policy was already in place and teachers were aware of it, although in general, it was not fully implemented. In this setting, they suggested that bringing in a program like TFT–TFS would strengthen the implementation of the school’s tobacco control policy. 2. Teachers and principals suggested seeking support from the DoE and felt that integrating the program into existing channels was crucial for its institutionalization: Teachers identified that support from the government was central to program adoption and its success. They explained that if the DoE supports a program like TFT–TFS, it would be more likely to be accepted among teachers. ‘So, if you can do some correspondence (receive support letters from/get the orders issued) with the help of Education Department saying that we support you … And for example, if few boards are hung in school … saying that, this is the tobacco-free campus … and if there is name of Education Department saying, please cooperate … Using this way will have more impact.’ ‘The letter from the DoE should say that the school should ensure that a teacher or a student or both together should be present. A motivational quote about the pollution created by tobacco to our environment … and we should get over(address) it … and control its consumption’. In both states, teachers and principals explained that they (mainly principals) do meet at the district/block level on a monthly basis for discussing school-related issues (progress, problem identification and solutions). Hence, they suggested utilizing this district/block level platform, with support from the DoE, to train principals in the TFT–TFS program; in this way, principals could implement the program at their schools and train other personnel in their school. ‘Madam (FGD Moderator), principals’ group is there in every district. It is in the block as well as in the district. Madam, we have regular monthly training. If we announce meeting in a district and if we invite all principals there … .if we provide a resource person for every block or district… .if we send him (to receive training)… . then it will be more effective’. In Maharashtra, teachers reported that there were a few Resource Persons (RP) selected from some of the schools who receive training at the state level. These RPs were responsible for disseminating the training to various school administrative units (district, block and cluster levels), ultimately extending the training to each school. They explained that this cascade model could be used for implementing the TFT–TFS program too. ‘Every program is conducted in this way … . State level then division level … . State-division-district (level) … . After district, block place and then cluster … . Cluster comes at the last’. The teachers and principals explained that the monthly staff meetings could be a potential avenue to implement the TFT–TFS program at the school level. ‘In every month there is a meeting of teachers on last working day of the month. On that day students have a holiday (but for teachers it is a working day). Head Master (principal) conducts a meeting. At that time, the Head Master will have to make a request, like… . give me 15 minutes more so that I can (discuss about the program)… . I think in this way the meeting can happen’.3. Principals and teachers identified several facilitators and barriers to the program implementation: They had suggested potential ways to implement tobacco control program in schools as quoted below. ‘Yes it is possible to implement the tobacco control policy in school of Bihar. It should be coordinated and district education officer should be advised to implement it in schools and principal should be made responsible for keeping his school tobacco free. He should strictly supervise that no one should consume tobacco in his school. If any teacher or staff is consuming, then principal should stop them and make them understand’. ‘Earlier, government of Maharashtra had issued G.R. (General Rule) regarding people seen smoking or chewing tobacco in the school campus. Fine will be charged for it within 200 m area. It is there but it is not implemented. It has to be little bit strict. That authority should be given to the principal at the school level. If he (principal) notices anybody then he should take his snap for proof and fine him or at least give him memo and forward it to his senior’. Teachers from Bihar felt that contributing to such a ‘noble cause’ (tobacco control) was a matter of pride. So, they expressed that teachers and principals should overcome barriers to implement this kind of program in their schools. ‘See, for any good work, we will have to spare some time. If we have to run a health program, then we will have to bring some change in our routine. We will have to adjust it into our routine only; then only it will get completed. If we organize this program after 4 p.m. (i.e. after office hours) then nobody will stay back. We will have to create such circumstances (make a special slot or deliberately bring-in some such occasions)’. In both states, teachers and principals mentioned that the principals and teachers who were tobacco users might not actively participate in the program like TFT–TFS initially. ‘There will be resistance. In spite of resistance, we have to implement this policy. Those who are addicted will resist this’. But they explained that tobacco-users would gradually learn to accept the program if schools have skilled principals, informative program materials and support letter issued from the DoE to each schools. ‘Principal should have special skill for such addicted people (tobacco users). Later, if we show him proofs or if we get those proofs (supporting information in terms of study materials) from you, then we can show those to them. They will understand it and maybe their feeling about tobacco will gradually change. That’s why I told that everything is not possible through law; principal must have good control and also good skills’. Teachers also discussed the importance of having appropriate skills (such as, not forcing anyone to quit, encouraging quitting by supporting teachers, respecting and appreciating tobacco users) to implement the TFT–TFS program and help others quit tobacco as stated in above quote. In Maharashtra, one teacher felt that teachers’ duty of teaching could be a potential barrier. ‘You should not interfere in the school time and that won’t be acceptable either. I have the right, if such a thing is happening … the school time is provided to us by the government for the school children … and the government pays us for that. If that time is used for such external activities, I oppose that’. However other teachers countered his opinion and mentioned that this could be overcome by proper planning. ‘You don’t need to give extra time. You have to discuss your opinions when teachers come together’. Teachers and principals from Maharashtra pointed out that tobacco use is particularly high in the rural community. ‘In rural areas, the percentage is 80% and it’s widely acceptable. The program will help them’. They explained that the tobacco shop is usually located within the vicinity of the schools. So, it might be challenging to implement the tobacco policy as a part of TFT–TFS program. ‘In my school … there are so many shops nearby it. Means there are paan shops within 100 yards area. If principal or teacher tries to shut it down then, environment of village will get spoiled (will create tension between school and villagers); students are also there in the school’. Teachers highlighted the importance of involving local, village and town governing bodies to support program implementation so that it would yield better results. They also felt that somehow few local non-governmental organizations could take up the responsibility of implementing this kind of program with the help of the DoE, to have a greater impact. ‘It can be done at any level… . rather it is the policy of government or local policy of school level. Until and unless it gets cooperation, it can never be implemented. But on small scale, it can be controlled like… . local government cell can have control in school, head of the village can control it in his respective village and principal can control in his own school’. Teachers and principals in both states felt that involvement of students in encouraging teachers to quit tobacco would be crucial and that might have greater influence on teachers. They also proposed arranging competitions among students, using tobacco as a theme, and giving the responsibility of facilitating such competitions to the teachers who use tobacco. ‘In school, competitions like elocution can be arranged, essay competitions, etc. through cultural division of school. Teachers (who use tobacco) should be appointed as jury… . the examiner of it (the competition)… .the person who is smoking. If essay competitions are arranged… .and if those are examined supervised by persons who smoke themselves… .then it will be at least 25% effective for him’. They also suggested potential ways to encourage tobacco users not to consume tobacco in the school as quoted below. ‘There is a way. Whenever any teacher consumes tobacco, students and other teachers will start clapping. By doing so, he will feel ashamed (of using tobacco) and hence he will avoid consuming (tobacco) during school hours, at least for 6 hours. And gradually he will quit’. Discussion Successful implementation starts with a supportive infrastructure [31]. Following prinicples of the SCM [23], the extent to which a program is adopted and implemented is influenced by life experiences, social relationships, organizational structures and societal influences, which can be operationalized as either mediating mechanisms or modifying conditions. In this study, we found that factors likely to influence the effectiveness of lead teachers and principals included potential parameters of their participation (e.g. likely time commitment, role they can play given other responsibilities) and perceptions of the level of external support needed for performing this function; and incentives for ongoing participation. Factors like certification and recognition by DoE were considered to be facilitators of the program adoption. Although several perceived barriers to program implementation were reported (e.g. teaching duties taking priority), teachers and principals felt that these barriers could be overcome with proper planning and the involvement of the government (DoE), students and community. Overall, teachers and principals were receptive to the TFT–TFS program and expressed their interest in adopting such program within the education system infrastructure. This may be because it was perhaps the only program geared towards improving teachers’ health as opposed to the students or community at large. Drawing on the growing literature on dissemination and implementation science [7, 21–22, 31–38], this research provides outlining factors that may influence organizations to adopt and implement effective interventions, such as a tobacco control intervention. Decision makers and other individuals involved in implementation make choices about their participation based on their own values, cultural norms, knowledge and beliefs about tobacco use, self-efficacy, interests and experiences as earlier demonstrated in other studies [33]. In this cultural context, we found that teachers saw their participation as role models for healthy behaviours, while tobacco use, though perceived as an unhealthy behaviour, was generally socially acceptable. Program adoption will be influenced by the external environment, including current policies, community resources and cultural factors [22, 31]. Similar to earlier studies [34, 39–41], the study participants recommended integrating the program into the existing educational system with the support from the DoE. Integration can be done during monthly meetings at the district level for conducting trainings and monthly staff meetings at the school level for implementing the program. State-wise differences were also observed in the study findings. Compared with teachers in Maharashtra, Bihar teachers received almost no professional development training and no health/wellness programming, including for tobacco control. In addition, fewer schools reported having a tobacco control policy in place, and there was less support provided at the cluster (lowest school administrative unit), block and district (highest school administrative unit) levels in Bihar compared with Maharashtra. These differences emphasize the need to tailor TFT–TFS to the context of different states. In addition to tobacco control, teachers also expressed interest in learning about how to reduce other NCD related risk factors. This study presents strategies to bridge the gap between research and practice, of particular importance to tobacco control, which might also contribute to NCD prevention efforts in LMICs. Therefore, integrating multiple risk factors control programs into one program might result in greater benefit to the health of teachers and possibly a more cost and time effective approach. In our study, we identified effective ways to implement the TFT–TFS program using existing channels, understanding that support from the DoE and other school personnel were crucial requirements in this process. With increasing global disparities in tobacco use and the burden rapidly shifting to the low-middle income countries [42], there is a significant need for effective strategies to promote tobacco use cessation in resource-poor settings [43–44]. The potential impact of this pilot study is significant because it provides a foundation for disseminating effective tobacco control interventions in LMIC’s, using a novel focus on school teachers who are key opinion leaders in their communities. There were however, limitations to this study. First, the data collected through the survey were self-reported and were subject to self-report bias. Several efforts were taken to mitigate the effect of this bias, such as using mixed methods of data collection (i.e. quantitative principal survey and qualitative principal and teacher FGDs). Second, this was a cross-sectional study and hence causal association could not be established. However, adding findings from the qualitative data has provided us the in-depth understanding of the state-specific infrastructures and the potential facilitators and barriers to the program adoption. Third, the lists of schools procured from the DoE were either incomplete or were not updated regularly and hence telephone survey response rates were low, thereby limiting the ability to generalize the findings. However, 97% of the survey school principals expressed their willingness to implement such program in their schools. Thus, the overall objective to generate an in-depth understanding of how to disseminate, implement and bring to scale a comprehensive tobacco control program aimed at supporting cessation among school teachers was achieved by utilizing both qualitative and quantitative methods. Qualitative methods complemented quantitative methods by providing detailed, contextually-based data on the discrete and subtle meanings associated with attitudes, beliefs and behaviours. When combined, they produce a synergistic effect and enhance comparison of results and critical reflection of the results [32, 45–46]. Conclusion Overall, teachers and principals were receptive to the TFT–TFS program and a high level of interest was expressed towards its implementation in their schools. These study findings not only demonstrate the similarities but also highlight the need for capitalizing on and adopting these findings to various local settings such as state specific school administrative units (clusters, blocks and districts). When implemented on a large scale, such interventions have the potential to contribute to prevent a large number of NCDs related to tobacco use; thereby saving lives by helping people quit and remain tobacco-free. Acknowledgements The authors thank the numerous investigators and staff members in India and the United States who contributed to this study, including Linnea Benson-Whelan, Ellen Connorton, Joshua Gagne, Benjamin Penningroth, Aishwarya Rathore, Sameer Narake, Rajesh Verma, Dr. Dhirendra Sinha, K. Viswanath and Lorraine Wallace. In addition, this work would not have been completed without the participation and help of the selected principals and staff of 166 schools in Bihar and 220 schools in Maharashtra and staff at the School of Preventive Oncology in Patna. Lastly, the authors also thank the Education Departments of the Bihar and the Maharashtra State Government for their support of this study. Funding This work was supported by the National Cancer Institute at the National Institutes of Health (5R01 CA120958, 5K05 A108663, 5P30 CA006516-48). Conflict of interest statement None declared. References 1 World Health Organization. Tobacco Factsheet . Available at: http://www.who.int/mediacentre/factsheets/fs339/en/. Accessed: May 2017. 2 World Health Organization . WHO report on the global tobacco epidemic, 2011 . Executive summary. Available at: http://whqlibdoc.who.int/hq/2011/WHO_NMH_TFI_11.3_eng.pdf.2011. 3 World Health Organization . Tobacco or Health: A Global Status Report: Country Profiles by Region . 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Scaling up a tobacco control intervention in low resource settings: a case example for school teachers in India

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Abstract

Abstract Research on processes of bringing effective tobacco control interventions to scale to increase quit rates among tobacco users is uncommon. This study examines processes to bring to scale one such intervention for school teachers, i.e. Tobacco Free Teacher–Tobacco Free Society (TFT–TFS). This intervention provides a foundation for an effective and low cost approach to promote cessation through schools. The present study was conducted in the states of Bihar and Maharashtra in 2014 using quantitative and qualitative methods. Focus group discussions (FGDs) were analysed using immersion crystallization method. The data presented are from a survey of 291 principals and seven FGDs. This study examined characteristics of principals and teachers, organizational environment, external environmental factors and program characteristics to determine facilitators and barriers for successful dissemination and implementation of the TFT–TFS program. Some facilitators were, incorporation of the program in existing channels like staff meetings and trainings, certification and recognition by the department of education; while some barriers were routine time bound duties (mainly teaching) of teachers and prevalence of tobacco use among teachers and administrators. Principals and teachers expressed a need and high level of interest in the adoption and implementation of the TFT–TFS program in their schools. Introduction Tobacco use kills more than 7 million people annually worldwide. More than six million of those deaths are the result of direct tobacco use, while, around 890,000 are the result of non-smokers being exposed to second-hand smoke. In the 20th century, 100 million tobacco deaths occurred; nearly 70% were in high-income countries [1]. In contrast, in the 21st century, tobacco is expected to kill about one billion people, mostly in low- and middle-income countries. The proportion of deaths attributed to tobacco use is rising rapidly in developing countries [2]. This is particularly important in India, where a large proportion of premature deaths, mainly due to tuberculosis and non-communicable diseases (NCDs), are caused by the use of tobacco in a variety of smoking and smokeless forms [3, 4]. In India, every year, 0.9 million persons are estimated to die prematurely due to smoking [5] and 0.35 million from smokeless tobacco use [6]. Although India was an early signatory to the Framework Convention on Tobacco Control, few resources are available to support tobacco use cessation [7–15]. Most smokers who quit often quit without assistance. If appropriate cessation interventions were made available, this may further increase quit rates [16]. With the increasing understanding of the public health impact of tobacco, there is a need for broad implementation of effective tobacco control interventions that promote tobacco use cessation and establish a social supportive environment [16]. Research on the processes of bringing such effective tobacco control interventions to scale has been sparse, and there is insufficient evidence to determine the most effective ways to promote tobacco cessation in low resource settings. Although few prior studies have paid attention to school teachers’ tobacco use, other school-based studies aimed at tobacco use prevention among students have examined factors contributing to broad-based implementation. For example, one study from India designed for students described how the evidence-based practices from two school-based tobacco control interventions were used to scale up these interventions at the national level across India [17]. Advocacy efforts were pursued through multiple channels, including assisting the government to develop evidence-based guidelines for school health programs. The study highlighted the importance of producing locally relevant research evidence and using strategic and sustained advocacy to translate research into practice that can be supported by the government. Similarly, dissemination/implementation research in the USA has explored factors contributing to scaling up successful programs. Similar to the Indian study, a randomized controlled trial from the USA tested a tobacco control program designed to reduce tobacco use among youth. When the program was proven to be effective, the study team identified key stakeholders who had important roles in program diffusion, adoption and maintenance. They found that school personnel, Department of Education (DoE) and other organizations with experience in national dissemination are crucial for effective dissemination of the program [18]. Based on these findings, nationally standardized protocols for program delivery, research and evaluation were developed. School teachers in India are an important resource for promoting tobacco control in schools and in society at large, given their roles as community leaders and role models. However, tobacco use among teachers is high: The Global School Personnel Survey, conducted in 2000, found that 78% of teachers in Bihar used some form of tobacco [19]. A tobacco use cessation intervention for school teachers called Tobacco Free Teachers–Tobacco Free Society (TFT–TFS), which included educational efforts, tobacco control policies and cessation support, was tested in a cluster randomized controlled trial in the Bihar School Teachers’ Study. This intervention was found to be effective in increasing tobacco use cessation among school teachers [20]. The TFT–TFS intervention was designed in response to the local social context and aimed to build on the social resources among teachers, who can help shape social norms and serve as role models for tobacco control in their communities. In the TFT–TFS intervention, a lead teacher was designated by the school principal to work with the project. These lead teachers were trained by project staff in the TFT–TFS program and the basics of tobacco control. Project health educators worked with a lead teacher in each school to deliver the program to all teachers. Immediately post-intervention, the 30-day quit rate was 50% in the intervention schools compared with 15% in the control schools; 9 months after the completion of the intervention, the 6-months quit rate was 19% in the intervention schools and 7% in the control schools [20]. This research thus provides the foundation for an effective intervention to promote cessation among school teachers in low-resource settings. The next logical step to put this research into practice was to develop and test strategies for delivering such interventions at a larger scale. Therefore, this pilot study was designed to better understand the gap between implementation and dissemination, and possible ways to accelerate the pace of dissemination of this type of tobacco control intervention in low resource settings [7, 21–22]. The Social Contextual Model (SCM) of Health Behaviour Change was used as a theoretical framework [23] to guide the organization of factors related to the perception of principals and potential lead teachers for implementing the TFT–TFS program. The overall objective of this pilot study was to generate an in-depth understanding of the factors associated with schools’ capability and willingness to adopt a comprehensive tobacco control program that will support cessation among school teachers. The specific aims of the study were to: (i) determine schools’ willingness to adopt a comprehensive tobacco use cessation intervention for teachers; (ii) describe the characteristics of organizations, school principals and the broader environment associated with schools’ willingness to adopt such programs and (iii) describe the perceptions of school principals and potential lead teachers of the feasibility and acceptability of implementing the TFT–TFS program, including identifying the need for any program adaptations. Materials and methods Study population This pilot study was conducted in the states of Bihar and Maharashtra in 2014. These two states were specifically selected considering the diversity of settings within India. In Bihar, resources are scarce, the supporting infrastructure thin, and prevalence of tobacco higher (53.5%) compared with Maharashtra (31.4%) [24]. This diversity was chosen to provide a broad-based understanding of the factors that may influence schools’ decisions to adopt tobacco control programs, which can enhance generalizability to other areas in India and elsewhere. This study included school principals and teachers of government and government-aided schools from rural and urban areas of Bihar and Maharashtra. Lists of 3909 eligible schools in 34 districts of Maharashtra and 1076 eligible schools in 10 districts of Bihar having grades 8–10 were obtained. These lists included the names and phone numbers of teachers and principals. Schools were identified through their districts (highest school administrative unit), and clusters (lowest school administrative unit), wherein a cluster was a sub-unit of the block and the block was a sub-unit of school districts in India. All schools having grades 8–10 and at least eight teachers were eligible to participate in the study. In Bihar, schools that participated in the BSTS were excluded from the eligible sample. Data collection methods The pilot study involved data collection through both quantitative and qualitative methods: (i) telephone surveys with principals of randomly selected schools; and (ii) focus groups with principals and potential lead teachers identified by schools’ principals. A structured survey instrument was used to conduct telephone interviews with 150 principals in each state. A verbal informed consent from principals was obtained. Telephone interviews were administered by trained survey administrators in Hindi and Marathi. Response rates were enhanced by making call attempts at various times of the day and week; and scheduling specific times to call back at the convenience of each respondent. For focus group discussions (FGDs), principals were invited to attend, and were asked to identify and invite a teacher from their school who would potentially play the role of a lead teacher. Schools participated in telephone interviews were excluded from FGDs to ensure their responses in the FGDs were not influenced by their participation in the survey. FGDs were conducted at a centralized location within each state, and were conducted by trained moderators who were involved in BSTS. FGDs were conducted in local languages in the respective states (Hindi in Bihar, Marathi in Maharashtra), transcribed, and translated into English. A total of seven focus groups were conducted in Bihar represented by 10 rural and 6 urban schools and in Maharashtra represented by 43 rural and 27 urban schools. Among these, three (one in Bihar and two in Maharashtra) FGDs were conducted with principals (n = 47) and four (two in each state) with potential lead teachers (n = 86) identified by respective school principals. About 15 participants were included in each FGD. An independent team of one moderator and one note taker were involved in each state. Measures The survey assessed individual characteristics of the principals (i.e. demographics, tobacco use history, self-efficacy, attitude towards and motivation to adopt tobacco control programs and policies) [25–26]; organizational characteristics of their schools (e.g. collective efficacy, organizational climate to adopt tobacco control programs and policies, shared sense of program goals and vision) [25, 27–29]; and characteristics of the school district or block (i.e. district/block demographics, relationship with DoE). Standard measures available in the literature, including the authors’ previous works, like utilizing the SCM [23] of Health Behaviour Change as a theoretical framework for examining association between social environment and tobacco use among teachers, were adapted for this study. For the qualitative data, an open-ended moderator guide was developed in which questions to be asked were specified. Moderators were allowed the flexibility to add fresh questions and to probe on relevant areas more fully, thus capitalizing on the strength of this technique. Questions explored perceptions of and reactions to the TFT–TFS program materials and approaches; applicability of these materials and approaches within their settings; factors and organizations most influential in decision-making regarding program offerings; barriers to and facilitators of adopting the TFT–TFS program materials and approaches; resources available to implement the program in schools; feasibility of the lead teacher roles including best ways to support their ongoing engagement; adaptations needed for them for the program; and optimal ways to promote it to school principals. Data analysis In order to recruit a pre-defined sample of 150 principals in each state to conduct telephone interviews, 402 principals in Bihar and 254 principals in Maharashtra were approached. Some 62% of principals in Bihar and 41% of principles in Maharashtra could not be recruited due to bad telephone numbers and 1% principals in Bihar refused to participate. Among the 300 surveyed school principals, nine principals answered ‘no’ to the question, ‘Are you interested in adopting the program in your school?’ Of these nine, two were from Bihar and seven were from Maharashtra. Out of these nine, only one principal from Maharashtra reported using tobacco. The most common reason for their non-interest was their unavailability including being busy with their academic work at the time this study was conducted. Thus, the survey analysis was restricted to 291 principals who reported their interest in adopting the program in their schools. Analysis of the survey data involved descriptive statistics of the school’s characteristics, perceptions about the value of tobacco control interventions, and willingness to adopt such programs. Point estimates were calculated with 95% confidence intervals for all measures (percentages), separately for the two states. Focus group discussions were analysed using immersion-crystallization method [30], which allowed the authors to conduct concentrated reviews of the data, to reflect upon them, and formulate independent interpretations before collectively agreeing upon the major ideas. Initial content analysis was done and broad recurring themes were identified by co-authors located in Mumbai, India. All verbatim quotes from the transcripts were recorded as stated by the respondents to prevent any loss of interpretation. The themes document was then shared with co-authors in Boston who independently reviewed, reflected upon and conducted their own data analysis. The investigators then ‘crystallized’ the diverse interpretations of the data until a final interpretation emerged. The results include key themes emerging (related to school personnel’s views about feasibility of adoption of program, potential facilitators and barriers and ways to integrate the program in existing system) which either supported or augmented the findings from the analyses of quantitative data. Ethical consideration Study methods and materials were approved by institutional review boards at the Harvard T. H. Chan School of Public Health in the United States and the Healis-Sekhsaria Institute for Public Health in India. The study protocol was reviewed and cleared by the Indian Council of Medical Research. Verbal informed consent was obtained for all data collection activities after assuring anonymity, and appropriate strategies for protecting study participants from any risks related to the research, including loss of confidentiality, were carefully followed. Results Survey results Respondent and school characteristics Out of 291 principals (Table I), most principals were men, 51 years of age or older, and had been a principal for over 20 years. Around 10% of principals from both states reported using of tobacco during the last 30 days. Regarding characteristics of the schools (Table II), 7.4% of schools in Bihar and 38.7% in Maharashtra reported having a written tobacco control policy. Fewer than 35% of principals from both states reported that tobacco education was provided to their teachers, while almost all principals from both states reported that tobacco education was provided to their students. Almost all principals from both states reported receiving curriculum training, mostly at the highest school administrative unit (i.e. district 98.6%) in Bihar and at every school administrative unit (i.e. the district 52.1%, cluster 61.7% and block 68.3%) in Maharashtra. There were large differences between the states in principals’ reporting that their teachers received other professional development trainings (in Bihar, 7.5%, and in Maharashtra, 61.5%). More than half of the principals reported that their teachers would be likely to spare time for non-teaching activities (in Maharashtra, 87.2%, and in Bihar, 54.7%). Table I. Characteristics of principals in Maharashtra and Bihar Demographics of principals and their perceptions about feasibility of adopting program Interested (N = 291) Maharashtra (n = 143) Bihar (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Characteristics of principals Sex Female 31 21.7 (15.7, 29.1) 34 23 (16.9, 30.4) Male 112 78.3 (70.9, 84.3) 114 77 (69.6, 83.1) Age of principal ≤40 6 4.6 (2.1, 9.6) 6 4.1 (1.9, 8.6) 41–50 32 24.4 (17.9, 32.5) 21 14.2 (9.5, 20.7) >50 93 71 (62.7, 78.1) 121 81.8 (74.8, 87.2) No. of years principal in education service ≤10 5 3.5 (1.5, 7.9) 17 11.5 (7.3, 17.6) 11–20 25 17.5 (12.1, 24.5) 8 5.4 (2.8, 10.3) 21–30 79 55.2 (47.1, 63.2) 55 37.2 (29.8, 45.2) >30 34 23.8 (17.6, 31.4) 68 45.9 (38.1, 54.0) No of years principal of this school 1 year 46 32.2 (25.1, 40.2) 51 34.5 (27.3, 42.4) 2–5 years 72 50.4 (42.3, 58.4) 67 45.3 (37.5, 53.3) >5 years 25 17.5 (12.1, 24.5) 30 20.3 (14.6, 27.5) Tobacco used in last 30 days Yes 14 10.1 (6.1, 16.2) 19 13 (8.5, 19.4) Demographics of principals and their perceptions about feasibility of adopting program Interested (N = 291) Maharashtra (n = 143) Bihar (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Characteristics of principals Sex Female 31 21.7 (15.7, 29.1) 34 23 (16.9, 30.4) Male 112 78.3 (70.9, 84.3) 114 77 (69.6, 83.1) Age of principal ≤40 6 4.6 (2.1, 9.6) 6 4.1 (1.9, 8.6) 41–50 32 24.4 (17.9, 32.5) 21 14.2 (9.5, 20.7) >50 93 71 (62.7, 78.1) 121 81.8 (74.8, 87.2) No. of years principal in education service ≤10 5 3.5 (1.5, 7.9) 17 11.5 (7.3, 17.6) 11–20 25 17.5 (12.1, 24.5) 8 5.4 (2.8, 10.3) 21–30 79 55.2 (47.1, 63.2) 55 37.2 (29.8, 45.2) >30 34 23.8 (17.6, 31.4) 68 45.9 (38.1, 54.0) No of years principal of this school 1 year 46 32.2 (25.1, 40.2) 51 34.5 (27.3, 42.4) 2–5 years 72 50.4 (42.3, 58.4) 67 45.3 (37.5, 53.3) >5 years 25 17.5 (12.1, 24.5) 30 20.3 (14.6, 27.5) Tobacco used in last 30 days Yes 14 10.1 (6.1, 16.2) 19 13 (8.5, 19.4) Table I. Characteristics of principals in Maharashtra and Bihar Demographics of principals and their perceptions about feasibility of adopting program Interested (N = 291) Maharashtra (n = 143) Bihar (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Characteristics of principals Sex Female 31 21.7 (15.7, 29.1) 34 23 (16.9, 30.4) Male 112 78.3 (70.9, 84.3) 114 77 (69.6, 83.1) Age of principal ≤40 6 4.6 (2.1, 9.6) 6 4.1 (1.9, 8.6) 41–50 32 24.4 (17.9, 32.5) 21 14.2 (9.5, 20.7) >50 93 71 (62.7, 78.1) 121 81.8 (74.8, 87.2) No. of years principal in education service ≤10 5 3.5 (1.5, 7.9) 17 11.5 (7.3, 17.6) 11–20 25 17.5 (12.1, 24.5) 8 5.4 (2.8, 10.3) 21–30 79 55.2 (47.1, 63.2) 55 37.2 (29.8, 45.2) >30 34 23.8 (17.6, 31.4) 68 45.9 (38.1, 54.0) No of years principal of this school 1 year 46 32.2 (25.1, 40.2) 51 34.5 (27.3, 42.4) 2–5 years 72 50.4 (42.3, 58.4) 67 45.3 (37.5, 53.3) >5 years 25 17.5 (12.1, 24.5) 30 20.3 (14.6, 27.5) Tobacco used in last 30 days Yes 14 10.1 (6.1, 16.2) 19 13 (8.5, 19.4) Demographics of principals and their perceptions about feasibility of adopting program Interested (N = 291) Maharashtra (n = 143) Bihar (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Characteristics of principals Sex Female 31 21.7 (15.7, 29.1) 34 23 (16.9, 30.4) Male 112 78.3 (70.9, 84.3) 114 77 (69.6, 83.1) Age of principal ≤40 6 4.6 (2.1, 9.6) 6 4.1 (1.9, 8.6) 41–50 32 24.4 (17.9, 32.5) 21 14.2 (9.5, 20.7) >50 93 71 (62.7, 78.1) 121 81.8 (74.8, 87.2) No. of years principal in education service ≤10 5 3.5 (1.5, 7.9) 17 11.5 (7.3, 17.6) 11–20 25 17.5 (12.1, 24.5) 8 5.4 (2.8, 10.3) 21–30 79 55.2 (47.1, 63.2) 55 37.2 (29.8, 45.2) >30 34 23.8 (17.6, 31.4) 68 45.9 (38.1, 54.0) No of years principal of this school 1 year 46 32.2 (25.1, 40.2) 51 34.5 (27.3, 42.4) 2–5 years 72 50.4 (42.3, 58.4) 67 45.3 (37.5, 53.3) >5 years 25 17.5 (12.1, 24.5) 30 20.3 (14.6, 27.5) Tobacco used in last 30 days Yes 14 10.1 (6.1, 16.2) 19 13 (8.5, 19.4) Table II. Characteristics of schools, stratified by state School demographics and other characteristics Interested (N = 291) Maharashtra (n = 143) Bihar (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Characteristics of schools Schools have a written tobacco policy Yes 55 38.7 (31.1, 46.9) 11 7.4 (4.2, 12.8) Tobacco education is provided to teachers Yes 48 34 (26.7, 42.2) 31 20.9 (15.2, 28.2) Tobacco education is taught to students Yes 115 81 (73.8, 86.6) 139 93.9 (88.9, 96.8) Teachers’ time for non-teaching activities per week beyond teaching students No Time 18 12.8 (8.2, 19.3) 67 45.3 (37.5, 53.3) <1 h 79 56 (47.8, 64.0) 27 18.2 (12.9, 25.2) 1–2 h 31 22 (16.0, 29.5) 45 30.4 (23.6, 38.2) >3 h 13 9.3 (5.4, 15.1) 9 6.1 (3.2, 11.2) School location Rural 66 46.2 (38.2, 54.3) 112 75.7 (68.2, 81.9) Supportive environment at cluster, block and district level for program implementation How often do you have contact with trainers from the Department of Education outside school at the district level? Weekly 19 13.4 (8.7, 20.0) 0 0 — Monthly 55 38.7 (31.1, 46.9) 146 98.6 (95.2, 99.6) Quarterly 33 23.2 (17.1, 30.8) 0 0 — Bi-annually 16 11.3 (7.1, 17.5) 0 0 — Annually 17 12 (7.6, 18.3) 0 0 — Never 2 1.4 (0.4, 5.0) 1 0.7 (0.1, 3.7) Not applicable 0 0 — 1 0.7 (0.1, 3.7) How often do you have contact with trainers from the Department of Education outside school at the block level? Weekly 38 26.8 (20.2, 34.6) 0 0 — Monthly 59 41.5 (33.8, 49.8) 0 0 — Quarterly 28 19.7 (14.0, 27.0) 0 0 — Bi-annually 10 7 (3.9, 12.5) 0 0 — Annually 5 3.5 (1.5, 8.0) 1 0.7 (0.1, 3.7) Never 2 1.4 (0.4, 5.0) 2 1.4 (0.4, 4.8) Not applicable 0 0 — 145 98 (94.2, 99.3) How often do you have contact with trainers from the Department of Education outside school at the cluster level? Weekly 39 27.7 (20.9, 35.6) 0 0 — Monthly 48 34 (26.7, 42.2) 1 0.7 (0.1, 3.7) Quarterly 29 20.6 (14.7, 28.0) 1 0.7 (0.1, 3.7) Bi-annually 11 7.8 (4.4, 13.4) 0 0 — Annually 12 8.5 (4.9, 14.3) 0 0 — Never 2 1.4 (0.4, 5.0) 1 0.7 (0.1, 3.7) Not applicable 0 0 — 145 98 (94.2, 99.3) Receipt of other trainings/programs Teachers receive curriculum training Yes 143 100 (97.4, 100) 135 91.8 (86.3, 95.3) Teachers receive other professional development training Yes 88 61.5 (53.4, 69.1) 11 7.5 (4.2, 12.9) In the last 2 years, teachers have been offered any health or wellness programs Yes 54 37.8 (30.2, 45.9) 16 10.8 (6.8, 16.8) School demographics and other characteristics Interested (N = 291) Maharashtra (n = 143) Bihar (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Characteristics of schools Schools have a written tobacco policy Yes 55 38.7 (31.1, 46.9) 11 7.4 (4.2, 12.8) Tobacco education is provided to teachers Yes 48 34 (26.7, 42.2) 31 20.9 (15.2, 28.2) Tobacco education is taught to students Yes 115 81 (73.8, 86.6) 139 93.9 (88.9, 96.8) Teachers’ time for non-teaching activities per week beyond teaching students No Time 18 12.8 (8.2, 19.3) 67 45.3 (37.5, 53.3) <1 h 79 56 (47.8, 64.0) 27 18.2 (12.9, 25.2) 1–2 h 31 22 (16.0, 29.5) 45 30.4 (23.6, 38.2) >3 h 13 9.3 (5.4, 15.1) 9 6.1 (3.2, 11.2) School location Rural 66 46.2 (38.2, 54.3) 112 75.7 (68.2, 81.9) Supportive environment at cluster, block and district level for program implementation How often do you have contact with trainers from the Department of Education outside school at the district level? Weekly 19 13.4 (8.7, 20.0) 0 0 — Monthly 55 38.7 (31.1, 46.9) 146 98.6 (95.2, 99.6) Quarterly 33 23.2 (17.1, 30.8) 0 0 — Bi-annually 16 11.3 (7.1, 17.5) 0 0 — Annually 17 12 (7.6, 18.3) 0 0 — Never 2 1.4 (0.4, 5.0) 1 0.7 (0.1, 3.7) Not applicable 0 0 — 1 0.7 (0.1, 3.7) How often do you have contact with trainers from the Department of Education outside school at the block level? Weekly 38 26.8 (20.2, 34.6) 0 0 — Monthly 59 41.5 (33.8, 49.8) 0 0 — Quarterly 28 19.7 (14.0, 27.0) 0 0 — Bi-annually 10 7 (3.9, 12.5) 0 0 — Annually 5 3.5 (1.5, 8.0) 1 0.7 (0.1, 3.7) Never 2 1.4 (0.4, 5.0) 2 1.4 (0.4, 4.8) Not applicable 0 0 — 145 98 (94.2, 99.3) How often do you have contact with trainers from the Department of Education outside school at the cluster level? Weekly 39 27.7 (20.9, 35.6) 0 0 — Monthly 48 34 (26.7, 42.2) 1 0.7 (0.1, 3.7) Quarterly 29 20.6 (14.7, 28.0) 1 0.7 (0.1, 3.7) Bi-annually 11 7.8 (4.4, 13.4) 0 0 — Annually 12 8.5 (4.9, 14.3) 0 0 — Never 2 1.4 (0.4, 5.0) 1 0.7 (0.1, 3.7) Not applicable 0 0 — 145 98 (94.2, 99.3) Receipt of other trainings/programs Teachers receive curriculum training Yes 143 100 (97.4, 100) 135 91.8 (86.3, 95.3) Teachers receive other professional development training Yes 88 61.5 (53.4, 69.1) 11 7.5 (4.2, 12.9) In the last 2 years, teachers have been offered any health or wellness programs Yes 54 37.8 (30.2, 45.9) 16 10.8 (6.8, 16.8) Table II. Characteristics of schools, stratified by state School demographics and other characteristics Interested (N = 291) Maharashtra (n = 143) Bihar (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Characteristics of schools Schools have a written tobacco policy Yes 55 38.7 (31.1, 46.9) 11 7.4 (4.2, 12.8) Tobacco education is provided to teachers Yes 48 34 (26.7, 42.2) 31 20.9 (15.2, 28.2) Tobacco education is taught to students Yes 115 81 (73.8, 86.6) 139 93.9 (88.9, 96.8) Teachers’ time for non-teaching activities per week beyond teaching students No Time 18 12.8 (8.2, 19.3) 67 45.3 (37.5, 53.3) <1 h 79 56 (47.8, 64.0) 27 18.2 (12.9, 25.2) 1–2 h 31 22 (16.0, 29.5) 45 30.4 (23.6, 38.2) >3 h 13 9.3 (5.4, 15.1) 9 6.1 (3.2, 11.2) School location Rural 66 46.2 (38.2, 54.3) 112 75.7 (68.2, 81.9) Supportive environment at cluster, block and district level for program implementation How often do you have contact with trainers from the Department of Education outside school at the district level? Weekly 19 13.4 (8.7, 20.0) 0 0 — Monthly 55 38.7 (31.1, 46.9) 146 98.6 (95.2, 99.6) Quarterly 33 23.2 (17.1, 30.8) 0 0 — Bi-annually 16 11.3 (7.1, 17.5) 0 0 — Annually 17 12 (7.6, 18.3) 0 0 — Never 2 1.4 (0.4, 5.0) 1 0.7 (0.1, 3.7) Not applicable 0 0 — 1 0.7 (0.1, 3.7) How often do you have contact with trainers from the Department of Education outside school at the block level? Weekly 38 26.8 (20.2, 34.6) 0 0 — Monthly 59 41.5 (33.8, 49.8) 0 0 — Quarterly 28 19.7 (14.0, 27.0) 0 0 — Bi-annually 10 7 (3.9, 12.5) 0 0 — Annually 5 3.5 (1.5, 8.0) 1 0.7 (0.1, 3.7) Never 2 1.4 (0.4, 5.0) 2 1.4 (0.4, 4.8) Not applicable 0 0 — 145 98 (94.2, 99.3) How often do you have contact with trainers from the Department of Education outside school at the cluster level? Weekly 39 27.7 (20.9, 35.6) 0 0 — Monthly 48 34 (26.7, 42.2) 1 0.7 (0.1, 3.7) Quarterly 29 20.6 (14.7, 28.0) 1 0.7 (0.1, 3.7) Bi-annually 11 7.8 (4.4, 13.4) 0 0 — Annually 12 8.5 (4.9, 14.3) 0 0 — Never 2 1.4 (0.4, 5.0) 1 0.7 (0.1, 3.7) Not applicable 0 0 — 145 98 (94.2, 99.3) Receipt of other trainings/programs Teachers receive curriculum training Yes 143 100 (97.4, 100) 135 91.8 (86.3, 95.3) Teachers receive other professional development training Yes 88 61.5 (53.4, 69.1) 11 7.5 (4.2, 12.9) In the last 2 years, teachers have been offered any health or wellness programs Yes 54 37.8 (30.2, 45.9) 16 10.8 (6.8, 16.8) School demographics and other characteristics Interested (N = 291) Maharashtra (n = 143) Bihar (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Characteristics of schools Schools have a written tobacco policy Yes 55 38.7 (31.1, 46.9) 11 7.4 (4.2, 12.8) Tobacco education is provided to teachers Yes 48 34 (26.7, 42.2) 31 20.9 (15.2, 28.2) Tobacco education is taught to students Yes 115 81 (73.8, 86.6) 139 93.9 (88.9, 96.8) Teachers’ time for non-teaching activities per week beyond teaching students No Time 18 12.8 (8.2, 19.3) 67 45.3 (37.5, 53.3) <1 h 79 56 (47.8, 64.0) 27 18.2 (12.9, 25.2) 1–2 h 31 22 (16.0, 29.5) 45 30.4 (23.6, 38.2) >3 h 13 9.3 (5.4, 15.1) 9 6.1 (3.2, 11.2) School location Rural 66 46.2 (38.2, 54.3) 112 75.7 (68.2, 81.9) Supportive environment at cluster, block and district level for program implementation How often do you have contact with trainers from the Department of Education outside school at the district level? Weekly 19 13.4 (8.7, 20.0) 0 0 — Monthly 55 38.7 (31.1, 46.9) 146 98.6 (95.2, 99.6) Quarterly 33 23.2 (17.1, 30.8) 0 0 — Bi-annually 16 11.3 (7.1, 17.5) 0 0 — Annually 17 12 (7.6, 18.3) 0 0 — Never 2 1.4 (0.4, 5.0) 1 0.7 (0.1, 3.7) Not applicable 0 0 — 1 0.7 (0.1, 3.7) How often do you have contact with trainers from the Department of Education outside school at the block level? Weekly 38 26.8 (20.2, 34.6) 0 0 — Monthly 59 41.5 (33.8, 49.8) 0 0 — Quarterly 28 19.7 (14.0, 27.0) 0 0 — Bi-annually 10 7 (3.9, 12.5) 0 0 — Annually 5 3.5 (1.5, 8.0) 1 0.7 (0.1, 3.7) Never 2 1.4 (0.4, 5.0) 2 1.4 (0.4, 4.8) Not applicable 0 0 — 145 98 (94.2, 99.3) How often do you have contact with trainers from the Department of Education outside school at the cluster level? Weekly 39 27.7 (20.9, 35.6) 0 0 — Monthly 48 34 (26.7, 42.2) 1 0.7 (0.1, 3.7) Quarterly 29 20.6 (14.7, 28.0) 1 0.7 (0.1, 3.7) Bi-annually 11 7.8 (4.4, 13.4) 0 0 — Annually 12 8.5 (4.9, 14.3) 0 0 — Never 2 1.4 (0.4, 5.0) 1 0.7 (0.1, 3.7) Not applicable 0 0 — 145 98 (94.2, 99.3) Receipt of other trainings/programs Teachers receive curriculum training Yes 143 100 (97.4, 100) 135 91.8 (86.3, 95.3) Teachers receive other professional development training Yes 88 61.5 (53.4, 69.1) 11 7.5 (4.2, 12.9) In the last 2 years, teachers have been offered any health or wellness programs Yes 54 37.8 (30.2, 45.9) 16 10.8 (6.8, 16.8) Facilitators and barriers for program implementation There was strong consensus on key facilitators to program adoption/implementation, including providing flexibility to integrate the program into staff meetings; involving parents and community; certifying teacher’s participation in the program and recognition of school by the DoE (see Table III). The recognition by the community was considered as a less important facilitator for principals of Bihar (13.2%) than principals of Maharashtra (90.8%). Table III. Perceptions of principals in Bihar and Maharashtra regarding facilitators and barriers of program implementation Perceptions of principals regarding facilitators and barriers Interested (N = 291) Maharashtra Bihar (n = 143) (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Facilitators to program implementation Flexibility to integrate program into staff meetings or trainings Strongly agree/Agree 130 90.9 (85.1, 94.6) 146 98.6 (95.2, 99.6) Integration of program content into students curriculum Strongly agree/Agree 139 97.9 (94.0, 99.3) 148 100 (97.5, 100.0) Involvement of community and parents in the program Strongly agree/Agree 126 88.1 (81.8, 92.4) 146 98.6 (95.2, 99.6) Program participation certificates for teachers Strongly agree/Agree 141 98.6 (95.0, 99.6) 146 98.6 (95.2, 99.6) Recognition of the school by the Department of Education Strongly agree/Agree 142 99.3 (96.1, 99.9) 140 94.6 (89.7, 97.2) Recognition of the school by the community Strongly agree/Agree 129 90.8 (84.9, 94.6) 20 13.5 (8.9, 19.9) Barriers to program implementation Obligatory duties of teachers Disagree/Strongly Disagree 62 43.4 (35.5, 51.6) 145 98 (94.2, 99.3) Very high prevalence of tobacco use among teachers Disagree/Strongly Disagree 93 79.5 (71.3, 85.8) 139 97.2 (93.0, 98.9) Very low prevalence of tobacco use among teachers Disagree/Strongly Disagree 97 82.9 (75.1, 88.7) 143 99.3 (96.2, 99.9) Tobacco use by decision makers Disagree/Strongly Disagree 92 80 (71.8, 86.3) 142 99.3 (96.1, 99.9) Teachers having health priorities other than tobacco Disagree/Strongly Disagree 94 65.7 (57.6, 73.0) 146 98.6 (95.2, 99.6) Perceptions of principals regarding facilitators and barriers Interested (N = 291) Maharashtra Bihar (n = 143) (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Facilitators to program implementation Flexibility to integrate program into staff meetings or trainings Strongly agree/Agree 130 90.9 (85.1, 94.6) 146 98.6 (95.2, 99.6) Integration of program content into students curriculum Strongly agree/Agree 139 97.9 (94.0, 99.3) 148 100 (97.5, 100.0) Involvement of community and parents in the program Strongly agree/Agree 126 88.1 (81.8, 92.4) 146 98.6 (95.2, 99.6) Program participation certificates for teachers Strongly agree/Agree 141 98.6 (95.0, 99.6) 146 98.6 (95.2, 99.6) Recognition of the school by the Department of Education Strongly agree/Agree 142 99.3 (96.1, 99.9) 140 94.6 (89.7, 97.2) Recognition of the school by the community Strongly agree/Agree 129 90.8 (84.9, 94.6) 20 13.5 (8.9, 19.9) Barriers to program implementation Obligatory duties of teachers Disagree/Strongly Disagree 62 43.4 (35.5, 51.6) 145 98 (94.2, 99.3) Very high prevalence of tobacco use among teachers Disagree/Strongly Disagree 93 79.5 (71.3, 85.8) 139 97.2 (93.0, 98.9) Very low prevalence of tobacco use among teachers Disagree/Strongly Disagree 97 82.9 (75.1, 88.7) 143 99.3 (96.2, 99.9) Tobacco use by decision makers Disagree/Strongly Disagree 92 80 (71.8, 86.3) 142 99.3 (96.1, 99.9) Teachers having health priorities other than tobacco Disagree/Strongly Disagree 94 65.7 (57.6, 73.0) 146 98.6 (95.2, 99.6) Table III. Perceptions of principals in Bihar and Maharashtra regarding facilitators and barriers of program implementation Perceptions of principals regarding facilitators and barriers Interested (N = 291) Maharashtra Bihar (n = 143) (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Facilitators to program implementation Flexibility to integrate program into staff meetings or trainings Strongly agree/Agree 130 90.9 (85.1, 94.6) 146 98.6 (95.2, 99.6) Integration of program content into students curriculum Strongly agree/Agree 139 97.9 (94.0, 99.3) 148 100 (97.5, 100.0) Involvement of community and parents in the program Strongly agree/Agree 126 88.1 (81.8, 92.4) 146 98.6 (95.2, 99.6) Program participation certificates for teachers Strongly agree/Agree 141 98.6 (95.0, 99.6) 146 98.6 (95.2, 99.6) Recognition of the school by the Department of Education Strongly agree/Agree 142 99.3 (96.1, 99.9) 140 94.6 (89.7, 97.2) Recognition of the school by the community Strongly agree/Agree 129 90.8 (84.9, 94.6) 20 13.5 (8.9, 19.9) Barriers to program implementation Obligatory duties of teachers Disagree/Strongly Disagree 62 43.4 (35.5, 51.6) 145 98 (94.2, 99.3) Very high prevalence of tobacco use among teachers Disagree/Strongly Disagree 93 79.5 (71.3, 85.8) 139 97.2 (93.0, 98.9) Very low prevalence of tobacco use among teachers Disagree/Strongly Disagree 97 82.9 (75.1, 88.7) 143 99.3 (96.2, 99.9) Tobacco use by decision makers Disagree/Strongly Disagree 92 80 (71.8, 86.3) 142 99.3 (96.1, 99.9) Teachers having health priorities other than tobacco Disagree/Strongly Disagree 94 65.7 (57.6, 73.0) 146 98.6 (95.2, 99.6) Perceptions of principals regarding facilitators and barriers Interested (N = 291) Maharashtra Bihar (n = 143) (n = 148) Count Column N % 95% confidence intervals Count Column N % 95% confidence intervals Facilitators to program implementation Flexibility to integrate program into staff meetings or trainings Strongly agree/Agree 130 90.9 (85.1, 94.6) 146 98.6 (95.2, 99.6) Integration of program content into students curriculum Strongly agree/Agree 139 97.9 (94.0, 99.3) 148 100 (97.5, 100.0) Involvement of community and parents in the program Strongly agree/Agree 126 88.1 (81.8, 92.4) 146 98.6 (95.2, 99.6) Program participation certificates for teachers Strongly agree/Agree 141 98.6 (95.0, 99.6) 146 98.6 (95.2, 99.6) Recognition of the school by the Department of Education Strongly agree/Agree 142 99.3 (96.1, 99.9) 140 94.6 (89.7, 97.2) Recognition of the school by the community Strongly agree/Agree 129 90.8 (84.9, 94.6) 20 13.5 (8.9, 19.9) Barriers to program implementation Obligatory duties of teachers Disagree/Strongly Disagree 62 43.4 (35.5, 51.6) 145 98 (94.2, 99.3) Very high prevalence of tobacco use among teachers Disagree/Strongly Disagree 93 79.5 (71.3, 85.8) 139 97.2 (93.0, 98.9) Very low prevalence of tobacco use among teachers Disagree/Strongly Disagree 97 82.9 (75.1, 88.7) 143 99.3 (96.2, 99.9) Tobacco use by decision makers Disagree/Strongly Disagree 92 80 (71.8, 86.3) 142 99.3 (96.1, 99.9) Teachers having health priorities other than tobacco Disagree/Strongly Disagree 94 65.7 (57.6, 73.0) 146 98.6 (95.2, 99.6) When asked about potential barriers to the program implementation, almost all principals from Bihar disagreed that any specific factor could serve as a barrier. In contrast, principals from Maharashtra felt that factors such as obligatory duties of teachers (56.6%); tobacco use by teachers (19%) or decision-makers (20%); and teachers having other health priorities (34.3%) could serve as barriers in the program adoption/implementation. Principals of Bihar reported higher interest in learning about tobacco control and control of other NCD risk factors than principals of Maharashtra (Fig. 1). However, interest in learning about tobacco control was lower than that of other health topics such as blood pressure management, diabetes screening and obesity prevention. Fig. 1. View largeDownload slide Principals (n = 291) interest in learning about health topics. Fig. 1. View largeDownload slide Principals (n = 291) interest in learning about health topics. Focus group discussion regarding facilitators and barriers of program implementation Several themes related to facilitators and barriers to adoption and implementation of the TFT–TFS program emerged across all focus group discussions. As the findings for both states were mostly similar, only combined findings are presented here. Specific themes emerged and the relevant verbatim quotes are presented below: 1. Teachers and principals expressed a need for a tobacco control program for teachers: Teachers and principals recognized the important role of teachers in the TFT–TFS program, as quoted below. ‘Being an ideal teacher, my behaviour in front of students and society, my status in the society should be good……So, that’s why it is important that I control myself.’ They also acknowledged that some teachers are addicted to tobacco, which was a matter of concern needing a response. ‘In our entire high school the percentage of addiction (to tobacco) is about 10%, because in secondary schools we get jobs very late (mainly because of additional 3 to 5 years of education is required to become eligible to serve as a secondary teacher and hence earning money starts late). So, the percentage of addiction is not very high; but, in primary school, the addiction is highest because after completing 10th (secondary education) or 12th (higher secondary education) they complete D. Ed. (one-year Diploma in Education) and get jobs as primary teacher (start earning money at an early age compared to secondary teachers) and then addiction starts… .’ Because teachers had not received any program related to tobacco control, they were interested in such programs. They mentioned that there were many health programs for students (e.g. on anaemia) and community responsibilities (e.g. collecting census data) that teachers were responsible for implementing. However, the TFT–TFS program was unique because teachers were the focus of the program. Additionally students and communities might also benefit from the program, as quoted below. ‘This tobacco de-addiction program is a very important point (program) that considers the health of teachers; if the teachers have good health then everything will be fine.’ In Bihar, teachers and principals generally reported that there was no tobacco control policy in place at the school level and it was essential to have a policy to reduce tobacco use among teachers. …; but, tobacco has become so worldwide acceptable that one teacher offers tobacco to another teacher even in front of their students.’ In Maharashtra, however, most of the teachers reported that the school tobacco control policy was already in place and teachers were aware of it, although in general, it was not fully implemented. In this setting, they suggested that bringing in a program like TFT–TFS would strengthen the implementation of the school’s tobacco control policy. 2. Teachers and principals suggested seeking support from the DoE and felt that integrating the program into existing channels was crucial for its institutionalization: Teachers identified that support from the government was central to program adoption and its success. They explained that if the DoE supports a program like TFT–TFS, it would be more likely to be accepted among teachers. ‘So, if you can do some correspondence (receive support letters from/get the orders issued) with the help of Education Department saying that we support you … And for example, if few boards are hung in school … saying that, this is the tobacco-free campus … and if there is name of Education Department saying, please cooperate … Using this way will have more impact.’ ‘The letter from the DoE should say that the school should ensure that a teacher or a student or both together should be present. A motivational quote about the pollution created by tobacco to our environment … and we should get over(address) it … and control its consumption’. In both states, teachers and principals explained that they (mainly principals) do meet at the district/block level on a monthly basis for discussing school-related issues (progress, problem identification and solutions). Hence, they suggested utilizing this district/block level platform, with support from the DoE, to train principals in the TFT–TFS program; in this way, principals could implement the program at their schools and train other personnel in their school. ‘Madam (FGD Moderator), principals’ group is there in every district. It is in the block as well as in the district. Madam, we have regular monthly training. If we announce meeting in a district and if we invite all principals there … .if we provide a resource person for every block or district… .if we send him (to receive training)… . then it will be more effective’. In Maharashtra, teachers reported that there were a few Resource Persons (RP) selected from some of the schools who receive training at the state level. These RPs were responsible for disseminating the training to various school administrative units (district, block and cluster levels), ultimately extending the training to each school. They explained that this cascade model could be used for implementing the TFT–TFS program too. ‘Every program is conducted in this way … . State level then division level … . State-division-district (level) … . After district, block place and then cluster … . Cluster comes at the last’. The teachers and principals explained that the monthly staff meetings could be a potential avenue to implement the TFT–TFS program at the school level. ‘In every month there is a meeting of teachers on last working day of the month. On that day students have a holiday (but for teachers it is a working day). Head Master (principal) conducts a meeting. At that time, the Head Master will have to make a request, like… . give me 15 minutes more so that I can (discuss about the program)… . I think in this way the meeting can happen’.3. Principals and teachers identified several facilitators and barriers to the program implementation: They had suggested potential ways to implement tobacco control program in schools as quoted below. ‘Yes it is possible to implement the tobacco control policy in school of Bihar. It should be coordinated and district education officer should be advised to implement it in schools and principal should be made responsible for keeping his school tobacco free. He should strictly supervise that no one should consume tobacco in his school. If any teacher or staff is consuming, then principal should stop them and make them understand’. ‘Earlier, government of Maharashtra had issued G.R. (General Rule) regarding people seen smoking or chewing tobacco in the school campus. Fine will be charged for it within 200 m area. It is there but it is not implemented. It has to be little bit strict. That authority should be given to the principal at the school level. If he (principal) notices anybody then he should take his snap for proof and fine him or at least give him memo and forward it to his senior’. Teachers from Bihar felt that contributing to such a ‘noble cause’ (tobacco control) was a matter of pride. So, they expressed that teachers and principals should overcome barriers to implement this kind of program in their schools. ‘See, for any good work, we will have to spare some time. If we have to run a health program, then we will have to bring some change in our routine. We will have to adjust it into our routine only; then only it will get completed. If we organize this program after 4 p.m. (i.e. after office hours) then nobody will stay back. We will have to create such circumstances (make a special slot or deliberately bring-in some such occasions)’. In both states, teachers and principals mentioned that the principals and teachers who were tobacco users might not actively participate in the program like TFT–TFS initially. ‘There will be resistance. In spite of resistance, we have to implement this policy. Those who are addicted will resist this’. But they explained that tobacco-users would gradually learn to accept the program if schools have skilled principals, informative program materials and support letter issued from the DoE to each schools. ‘Principal should have special skill for such addicted people (tobacco users). Later, if we show him proofs or if we get those proofs (supporting information in terms of study materials) from you, then we can show those to them. They will understand it and maybe their feeling about tobacco will gradually change. That’s why I told that everything is not possible through law; principal must have good control and also good skills’. Teachers also discussed the importance of having appropriate skills (such as, not forcing anyone to quit, encouraging quitting by supporting teachers, respecting and appreciating tobacco users) to implement the TFT–TFS program and help others quit tobacco as stated in above quote. In Maharashtra, one teacher felt that teachers’ duty of teaching could be a potential barrier. ‘You should not interfere in the school time and that won’t be acceptable either. I have the right, if such a thing is happening … the school time is provided to us by the government for the school children … and the government pays us for that. If that time is used for such external activities, I oppose that’. However other teachers countered his opinion and mentioned that this could be overcome by proper planning. ‘You don’t need to give extra time. You have to discuss your opinions when teachers come together’. Teachers and principals from Maharashtra pointed out that tobacco use is particularly high in the rural community. ‘In rural areas, the percentage is 80% and it’s widely acceptable. The program will help them’. They explained that the tobacco shop is usually located within the vicinity of the schools. So, it might be challenging to implement the tobacco policy as a part of TFT–TFS program. ‘In my school … there are so many shops nearby it. Means there are paan shops within 100 yards area. If principal or teacher tries to shut it down then, environment of village will get spoiled (will create tension between school and villagers); students are also there in the school’. Teachers highlighted the importance of involving local, village and town governing bodies to support program implementation so that it would yield better results. They also felt that somehow few local non-governmental organizations could take up the responsibility of implementing this kind of program with the help of the DoE, to have a greater impact. ‘It can be done at any level… . rather it is the policy of government or local policy of school level. Until and unless it gets cooperation, it can never be implemented. But on small scale, it can be controlled like… . local government cell can have control in school, head of the village can control it in his respective village and principal can control in his own school’. Teachers and principals in both states felt that involvement of students in encouraging teachers to quit tobacco would be crucial and that might have greater influence on teachers. They also proposed arranging competitions among students, using tobacco as a theme, and giving the responsibility of facilitating such competitions to the teachers who use tobacco. ‘In school, competitions like elocution can be arranged, essay competitions, etc. through cultural division of school. Teachers (who use tobacco) should be appointed as jury… . the examiner of it (the competition)… .the person who is smoking. If essay competitions are arranged… .and if those are examined supervised by persons who smoke themselves… .then it will be at least 25% effective for him’. They also suggested potential ways to encourage tobacco users not to consume tobacco in the school as quoted below. ‘There is a way. Whenever any teacher consumes tobacco, students and other teachers will start clapping. By doing so, he will feel ashamed (of using tobacco) and hence he will avoid consuming (tobacco) during school hours, at least for 6 hours. And gradually he will quit’. Discussion Successful implementation starts with a supportive infrastructure [31]. Following prinicples of the SCM [23], the extent to which a program is adopted and implemented is influenced by life experiences, social relationships, organizational structures and societal influences, which can be operationalized as either mediating mechanisms or modifying conditions. In this study, we found that factors likely to influence the effectiveness of lead teachers and principals included potential parameters of their participation (e.g. likely time commitment, role they can play given other responsibilities) and perceptions of the level of external support needed for performing this function; and incentives for ongoing participation. Factors like certification and recognition by DoE were considered to be facilitators of the program adoption. Although several perceived barriers to program implementation were reported (e.g. teaching duties taking priority), teachers and principals felt that these barriers could be overcome with proper planning and the involvement of the government (DoE), students and community. Overall, teachers and principals were receptive to the TFT–TFS program and expressed their interest in adopting such program within the education system infrastructure. This may be because it was perhaps the only program geared towards improving teachers’ health as opposed to the students or community at large. Drawing on the growing literature on dissemination and implementation science [7, 21–22, 31–38], this research provides outlining factors that may influence organizations to adopt and implement effective interventions, such as a tobacco control intervention. Decision makers and other individuals involved in implementation make choices about their participation based on their own values, cultural norms, knowledge and beliefs about tobacco use, self-efficacy, interests and experiences as earlier demonstrated in other studies [33]. In this cultural context, we found that teachers saw their participation as role models for healthy behaviours, while tobacco use, though perceived as an unhealthy behaviour, was generally socially acceptable. Program adoption will be influenced by the external environment, including current policies, community resources and cultural factors [22, 31]. Similar to earlier studies [34, 39–41], the study participants recommended integrating the program into the existing educational system with the support from the DoE. Integration can be done during monthly meetings at the district level for conducting trainings and monthly staff meetings at the school level for implementing the program. State-wise differences were also observed in the study findings. Compared with teachers in Maharashtra, Bihar teachers received almost no professional development training and no health/wellness programming, including for tobacco control. In addition, fewer schools reported having a tobacco control policy in place, and there was less support provided at the cluster (lowest school administrative unit), block and district (highest school administrative unit) levels in Bihar compared with Maharashtra. These differences emphasize the need to tailor TFT–TFS to the context of different states. In addition to tobacco control, teachers also expressed interest in learning about how to reduce other NCD related risk factors. This study presents strategies to bridge the gap between research and practice, of particular importance to tobacco control, which might also contribute to NCD prevention efforts in LMICs. Therefore, integrating multiple risk factors control programs into one program might result in greater benefit to the health of teachers and possibly a more cost and time effective approach. In our study, we identified effective ways to implement the TFT–TFS program using existing channels, understanding that support from the DoE and other school personnel were crucial requirements in this process. With increasing global disparities in tobacco use and the burden rapidly shifting to the low-middle income countries [42], there is a significant need for effective strategies to promote tobacco use cessation in resource-poor settings [43–44]. The potential impact of this pilot study is significant because it provides a foundation for disseminating effective tobacco control interventions in LMIC’s, using a novel focus on school teachers who are key opinion leaders in their communities. There were however, limitations to this study. First, the data collected through the survey were self-reported and were subject to self-report bias. Several efforts were taken to mitigate the effect of this bias, such as using mixed methods of data collection (i.e. quantitative principal survey and qualitative principal and teacher FGDs). Second, this was a cross-sectional study and hence causal association could not be established. However, adding findings from the qualitative data has provided us the in-depth understanding of the state-specific infrastructures and the potential facilitators and barriers to the program adoption. Third, the lists of schools procured from the DoE were either incomplete or were not updated regularly and hence telephone survey response rates were low, thereby limiting the ability to generalize the findings. However, 97% of the survey school principals expressed their willingness to implement such program in their schools. Thus, the overall objective to generate an in-depth understanding of how to disseminate, implement and bring to scale a comprehensive tobacco control program aimed at supporting cessation among school teachers was achieved by utilizing both qualitative and quantitative methods. Qualitative methods complemented quantitative methods by providing detailed, contextually-based data on the discrete and subtle meanings associated with attitudes, beliefs and behaviours. When combined, they produce a synergistic effect and enhance comparison of results and critical reflection of the results [32, 45–46]. Conclusion Overall, teachers and principals were receptive to the TFT–TFS program and a high level of interest was expressed towards its implementation in their schools. These study findings not only demonstrate the similarities but also highlight the need for capitalizing on and adopting these findings to various local settings such as state specific school administrative units (clusters, blocks and districts). When implemented on a large scale, such interventions have the potential to contribute to prevent a large number of NCDs related to tobacco use; thereby saving lives by helping people quit and remain tobacco-free. Acknowledgements The authors thank the numerous investigators and staff members in India and the United States who contributed to this study, including Linnea Benson-Whelan, Ellen Connorton, Joshua Gagne, Benjamin Penningroth, Aishwarya Rathore, Sameer Narake, Rajesh Verma, Dr. Dhirendra Sinha, K. Viswanath and Lorraine Wallace. In addition, this work would not have been completed without the participation and help of the selected principals and staff of 166 schools in Bihar and 220 schools in Maharashtra and staff at the School of Preventive Oncology in Patna. Lastly, the authors also thank the Education Departments of the Bihar and the Maharashtra State Government for their support of this study. Funding This work was supported by the National Cancer Institute at the National Institutes of Health (5R01 CA120958, 5K05 A108663, 5P30 CA006516-48). Conflict of interest statement None declared. References 1 World Health Organization. Tobacco Factsheet . Available at: http://www.who.int/mediacentre/factsheets/fs339/en/. Accessed: May 2017. 2 World Health Organization . WHO report on the global tobacco epidemic, 2011 . Executive summary. Available at: http://whqlibdoc.who.int/hq/2011/WHO_NMH_TFI_11.3_eng.pdf.2011. 3 World Health Organization . Tobacco or Health: A Global Status Report: Country Profiles by Region . 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For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Health Education ResearchOxford University Press

Published: May 10, 2018

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