Strengthening tobacco cessation capacity in India

5-panda


Dr. Rajmohan Panda
Public Health Foundation of India, Delhi
5-flag India
17 Mar 2015

Dr. Rajmohan Panda is a researcher with the Public Health Foundation of India, Delhi. His project, Strengthening Cessation Capacity in the National Tobacco Control Programme of India is one of 19 projects awarded grants through a partnership between Pfizer Independent Grants for Learning & Change (IGLC) and Global Bridges. The $2.3 million in grant awards are designed to increase tobacco cessation rates through healthcare professional training and advocacy in low- and middle-income countries.

The goal of your grant project is to strengthen cessation capacity in the National Tobacco Control Programme of India. Please give us an overview of how the project will accomplish this:

The project will be rolled out in two states of India — Rajasthan and Odisha. We will be training health care personnel drawn from the National Tobacco Control Programme (NTCP) at the state level, state health department, training division of the National Health mission, faculty of reputed medical colleges and regional cancer societies.

The training will initially develop a cadre of 100 master mentors in tobacco cessation in each state/region who will further train and mentor approximately 400 other health care providers in tobacco cessation through a cascade training method. These master mentors will become the eyes and ears of the programme who will advocate for cessation in their institutions. The 400 trained personnel will be a mixture of mostly primary care physicians, and some specialists such as cardiologists, pulmonologists, TB chest physicians and oncologists. Apart from training in cessation, they will also be trained to advocate for prioritization of cessation in clinical practices across the country.

We intend to provide a bouquet of online-course options ranging from brief interventions to three-month intensive cessation certificate courses. The training would be conducted through a hybrid model comprising of both face-to-face contact classes and online webinars and classes. The trainings will be designed in a way so that they provide an opportunity for a stimulating exchange of ideas and experiences among participants working in tobacco cessation regionally and nationally.

We are also considering doing a small mobile health component in the project where we are also testing some low-cost technology to see if we can use it for specific groups like urban Non-Communicable Diseases Clinics, adolescents and information technology workforce members.

This project is innovative and will help in overcoming a significant gap in tobacco cessation in the country by creating a network of cessation experts.

We will also be establishing a formal research and practice platform which will connect researchers with policy makers and program managers. This will help in the creation of a “community of practice” in tobacco control. We will build upon the “best practices” learned during our ongoing and previous work aimed at strengthening the health system in tobacco cessation to scale up the program in both states subsequently and then in the rest of the NTCP districts in the country. The online course that we build will stay on even after the project period is over and we hope to make this a nonprofit business model in the future.

How do you plan to highlight and spread awareness among health care professionals about the vital need for integrating cessation into routine clinical practices?

The tobacco cessation project will work as a network between the mentors and the physician’s health care unit. Approximately 10 master mentors from each district will be in charge of the physician-led health care unit to ensure the integration of cessation into routine clinical practice. Each team will constitute a Master Mentor, who is mentoring a four physician-led health care unit. Each of the four intervention districts in each state will have 12 such teams.

The best performing team will receive an incentive of some form post completion of the project. The team will be judged on the basis of training completion rate, number of patients advised, cessation rates and knowledge evaluation scores. All of this will be highlighted in the districts where we are only reaching out to a critical but small handful of health care units. Our outreach will help disseminate these innovative practices and create the need for integrating cessation into practices. By doing a detailed patient follow-up and highlighting some best case scenarios we hope to generate a positive demand for cessation throughout the district.

Once we are fairly convinced about the success of these units we are going to write media pieces and highlight the work so that it is picked up through the review of the national health missions which are held periodically during December and January every year. Once the review mission picks up these as best practices it will receive a lot of attention throughout the country. We are also using the resources to develop a low-cost online training model. This will be a low bandwidth online portal so that it can be easily accessible from the rural area with free access to all cessation resources. Apart from knowledge creation online we are also doing face-to-face motivation sessions in the districts. Certification and increasing the knowledge base along with positive motivation will help in the creation of a network of practioners who would be interested in integration of cessation into their clinical practices.The project has a robust evaluation component which will help the project to demonstrate the impact. This will be widely disseminated and help in strengthening evidence-based cessation practice. We are also using a wide variety of social and print media to build a brand image of the project to attract health care professionals to undertake the trainings so that we can disseminate the message of cessation.

How do you plan to test different approaches for policy implications?

We are planning to test two arms of intervention in which we will see the multiple as well as singular benefit and applicability of these arms. One arm is a package of brief intervention, the other is intensive intervention. The evidence of success and challenges of both arms post-evaluation will be presented to policy makers so that they can have an informed decision to pave future cessation strategies formulation for state health system.

We believe that a standard model is not the “best fit for all.”  As part of the approval process we spend a considerable amount of time with program managers and policy makers at center and state level to engage them with the project goals and objectives and took their inputs for design of the model. We will also organize consultations at different levels with key policy makers and program managers to establish the primary care model for tobacco cessation in the state. Ultimately the success of the project will lie on how well the state owns the project and takes it forward in other districts.

You have mentioned that policy makers often ask about the cost of these types of programs. How do you plan to address this? 

We are planning to do the costing exercise for all the intervention arms using the cost-effectiveness analysis (CEA). We will compare the cost effectiveness of the different interventions. We will also try to estimate the cost per quit from the system perspective. This will give us an idea about the cost for such type of evidence-based primary care cessation intervention. This is the first time such comprehensive costing is being planned in a cessation program in India and we plan on highlighting this in various national and international forums to generate interest in the project.