Health Care Initiative and Rationale for Choice
India is a low-middle-income country, as its GNI per capita calculated using the Atlas method was around 1,900 current US dollars in 2020 (The World Bank, 2020). At the same time, in 2020, India ranked 131 out of 189 participants in HDI, being placed in the category of Medium human development (UNDP, 2020), much below the world average. One of the problematic areas for India is connected to smoking and subsequent health issues. For instance, the number of male smokers in India increased by 36% between 1998 and 2015 (Daily News and Analysis, 2016). This is especially true for illiterate men; among them, the number of smokers rose 3.6 times. In 2010 alone, smoking caused about 1 million deaths in India, which is around 10% of all deaths for that year. Overall, India is “the second-largest consumer of tobacco globally, and accounts for approximately one-sixth of the world’s tobacco-related deaths” (Mishra et al., 2012). Furthermore, India is perceived as the “oral cancer capital” of the world based on the Global Adult Tobacco Survey data (Gambhir et al., 2016).
Dozens of anti-tobacco, anti-smoking, and anti-bidi campaigns have been launched in India in recent years as various local and international organizations, governments, and communities contributed to the fight against tobacco usage. These efforts demonstrated some effectiveness – “there has been a decline in the prevalence of smokeless tobacco use, from 25.9% to 21.4% and a decline in smoking, from 14.0% to 10.7%” (Lahoti & Dixit, 2021, p.1). On the other hand, India is still a country that has the most tobacco consumers in absolute terms.
Therefore, due to the widespread prevalence of smoking, and its devastating outcomes on individual and community health, smoking and tobacco use were chosen as a field for healthcare intervention. This is a focus of the Tobacco Intervention Initiative (TII) that my organization is a part of. The main goal of the TII is to reduce the number of deaths and diseases due to tobacco consumption by raising awareness about the outcomes of this process (Thelwell, 2020). The overall strategy involves establishing tobacco cessation centers, training dental professionals, creating awareness, promoting research, coordinating efforts of different actors, etc. TII is part of the National Oral Health Program created by the Indian Dental Association to improve the country’s overall health. The initiative implies training specialists to counsel the citizens on the matter. At the same time, oral healthcare professionals are encouraged to join the initiative and implement tobacco intervention and prevention methods in their care. The ultimate goal of TII is a “tobacco-free India” by 2022.
Situational Analysis
The WHO situational analysis framework was used to evaluate the situation regarding the usage of tobacco in India. It was chosen as it is a flexible tool for comprehensive analysis, applicable in different situations. Essentially, the WHO situational analysis tool was designed as a questionnaire to collect necessary information regarding health issues in a country (WHO, 2015). The first stage of situational analysis that will be reflected in this study involves desk-based data collection regarding country profile, the burden of disease, health status indicators and other factors. For the Tobacco Intervention Initiative, the following factors were analyzed: determinants of health, population needs and expectations, health system performance, capacity and available resources.
Initiative
The TII initiative mentioned above is expected to bring a massive change to the current situation in India. Specifically, the initiative will be aimed at raising awareness about the dangers of smoking and the health issues that it entails, including the possibility of lung cancer. Additionally, people with high tobacco dependency will be provided with therapy, counseling, and medications that will alleviate their craving for tobacco,
The initiative in question is largely supported by national trends in the target setting. Indeed, reports assert that the percentage of smoking adults has increased to 34% in India over the past decade (“World No Tobacco Day: 34.6 percent adults in India are smokers,” 2019). Therefore, the initiative has strong grounds to be introduced into the target setting. However, due to the lack of incentive for changing their lifestyle, the target audiences may dismiss the offered opportunity, which is why an awareness campaign must be carried out to draw public attention to the problem.
Health system performance
Health system performance is another concern to be addressed. The quality of the health system performance in India can be defined as moderate, with a substantial amount of resources being introduced, while the availability of the services remains questionable (Thakur & Paika, 2018). Therefore, supporting the current healthcare system with the introduction of PII should be considered essential.
In the context of TII and its goals, the main external factors include the impact of social media and popular culture, the resulting peer pressure, and the marketing techniques that tobacco companies utilize. Each of the specified factors has a large influence on the target population, minimizing the efforts of TII. Moreover, the fact that these influences are interconnected makes the effect of the overall influence almost irreversible (Kostygina et al., 2020).
In turn, the internal factors defining the success of TII includes the extent of cooperation and coordination of actions within the program. In addition, the factors such as the availability of a broad range of resources, including the opportunity to engage the target audience in a dialogue via social networks, create rather favorable conditions (Sanders et al., 2018). However, the lack of alternative sources for funding may represent an issue.
WHO Framework
Determinants of tobacco usage
There are various factors that affect tobacco usage within the Indian population. These factors may depend on the age of consumers, their gender, their geographical location, socio-economic status, the influence of others, types of tobacco products used, etc. Multiple studies that reflect different aspects of tobacco users will be reviewed in this section.
Regarding the younger population, their behavior may depend highly on the social norms they adopt from adults. According to the study by Ladusingh et al. (2017), conducted in India, parents’ tobacco usage behavior can directly affect their children’s tobacco usage patterns. It was concluded that “the likelihood of using tobacco was found to be 3.4 and 1.14 times more for the youths coresiding with mothers who use tobacco and fathers who use tobacco” (Ladusingh, 2017, p.1). In both cases, the probabilities were compared to those of youngsters whose parents did not consume any tobacco products.
Additionally, the role of peer pressure is not to be underestimated when it comes to evaluating the factors that incline Indian citizens toward smoking. The described effect should be considered in conjunction with the high levels of exposure to the habit of smoking. Specifically, due to the regular and pervasive advertisements issued by tobacco companies and broadcasted on nearly every type of media, Indian people, especially young ones, are forced to accept smoking as a part of popular culture (Ladusingh, 2017). As a result, Indian people develop the habit of smoking at a particularly young age, which makes further efforts of abandoning the need for smoking particularly difficult (Ladusingh, 2017).
Therefore, to address the current situation in India, it is vital to construct a program the influence of which will be significantly higher and greater in scope than those of the campaigns launched by tobacco companies in India. At first glance, the described outcome is nearly impossible, given the tremendous economic power that tobacco firms hold within the industry, including in the Indian setting (Thakur & Paika, 2018). However, at a second glance, one will notice the increasingly high effect of social media as the mean of engaging young people in political and social activism, as well as the tool for building awareness in general audiences. Indeed, due to the increased outreach, social media has been affecting the lives of a tremendous number of people, including Indian citizens (Thelwell, 2020). Therefore, by conducting an online campaign and advertising it with the help of social media, one will be capable of attracting the majority of the target population and, most importantly, convincing them of the harm that smoking can cause.
Finally, the issue of awareness should be mentioned as one of the driving factors in Indian people being increasingly inclined to use tobacco. Because of the absence of campaigns that could explain the harms of smoking to the target population, as well as the available health management resources that would insist on the importance of leading a healthy lifestyle, an increasing number of Indian people accept smoking as an inevitable part of their lives (Ladusingh, 2017). Combined with the factors listed above, the absence of awareness about the effects that smoking may entail, as well as the lack of mental health literacy in regard to managing bad habits, has an effect that is truly devastating in its scale.
Regarding dual use of smoked tobacco and SLT, there is a notable decreasing trend. “Findings reveal that dual-use has declined in India from nearly 5% in 2009–10 to 3.4% in 2016–17” (Singh et al., 2020, p.1). Such factors as education and income had negative relationships with dual tobacco use – more educated people and wealthier people tend to dual-use tobacco less often. At the same time, age was positively correlated with dual-use; and men practiced it more often than women. Finally, awareness about the negative health effects of tobacco consumption reduced the likelihood of dual usage, in the same way, it influenced each type of usage in particular.
Expectations and demands for services
As it was mentioned before, various anti-tobacco campaigns have been launched across India in recent years. However, the health system’s performance has been rather mediocre. Currently, a significant number of Indian people do not have access to vital healthcare services (Singh et al., 2020). In addition, health education has not been conducted properly, causing low health literacy rates (Thakur & Paika, 2018). In turn, TII is expected to be an entirely different program that is guaranteed to lead to positive results by increasing health literacy and providing active support and consultations to smokers. First and most important, it is expected that TII‘s services in question will help to increase health literacy among Indian people and particularly, will provide education about the dangers of smoking as a tremendously harmful habit (Singh et al., 2020). It is expected that the introduction of the TII program into the target setting will reduce the levels of smoking by 40% within the first 6 months.
Stakeholders’ Positions and Attitudes
Presently, several stakeholders can be identified in the fight against the increasingly widespread phenomenon of tobacco use in Indian people. First, the citizens who smoke or are prone to developing the habit of excessive smoking are deemed as the primary stakeholders of the TII program. In the course of the program implementation, it is expected to help the target population to shape their attitudes toward the phenomenon of smoking by recognizing the arm that it does to their digestive system (primarily, their teeth), as well as the respiratory one, including the threat of developing lung cancer (Singh et al., 2020). Currently, the positions and attitudes of the specified stakeholders vary to an extent, yet mostly agree on the idea that smoking has a minimal effect on people’s health (Mishra et al., 2012). The specified opinion must be challenged so that a positive change could be introduced into the Indian community, encouraging the target demographic to abandon the habit of smoking and adopt healthier lifestyles.
The tobacco industry of India is another important stakeholder in this case. Being the supplier of the product that causes immense harm to Indian people, the companies working within the industry are highly unlikely to accept and acknowledge the adverse effects of their activities. Nevertheless, there are ways of reducing the effect that these companies have on changing the mindset of Indian people, particularly, the impressionable youth. For example, challenging the appeal that the current image of the industry has to the target population could be a possible solution (Gambhir et al., 2016). Namely, prohibiting organizations to promote their products in a way that glamourizes smoking could be a solution.
Additionally, dentists should be seen as key stakeholders in the described initiative. It is believed that dentists will benefit from the introduction of the TII initiative since it will invite the opportunity to share experiences. Moreover, insights about the means of managing dental issues in patients with a smoking habit will be discussed profusely.
IDA will also be affected by the TII initiative substantially. Namely, with the introduction of the initiative, IDA will gain an opportunity to bring awareness to the Indian population. Thus, the levels of public health, particularly, the efficacy o dental self-care, will rise, which is one of IDA’s key concerns.
Finally, the government represents another key stakeholder in the described discourse. The TII initiative will provide the government with an opportunity to address a major public health issue, thus, ensuring the safety of Indian citizens. Therefore, TII will provide an opportunity for the Indian government to enhance the safety of the Indian population.
Health sector response, capacity and resources
In this section, the state-initiated campaigns, policies, and efforts to combat tobacco usage will be reviewed and assessed. It is believed that the response to be obtained from the health sector will be mostly positive. Specifically, health hazards faced by a significant percentage of the Indian population due to smoking have already attracted the attention of a large number of global entities and health organizations. For instance, the World Health Organization (WHO) has recently published a report declaring that Indian public health is under a significant threat due to the increase in smoking (World Health Organization, 2021). Outlining that the tobacco industry has been flourishing due to the presence of local traditions of smoking tobacco and its products such as khaini, zarda, gutkha, betel, and quid (World Health Organization, 2021). Moreover, the report highlights an increase in the number of deaths caused by the health issues occurring as a result of smoking to a total of 1% (World Health Organization, 2021). At first glance, the specified figures do not seem particularly threatening; however, after realizing that the current population of India constitutes around 1.4 billion people, one will discover that around 14 million people are, therefore, doomed to death due to the increase in the rates of smoking (World Health Organization, 2021). Therefore, the TII framework must address the issue immediately to avoid its further aggravation and the exponential growth in the number of victims. For this reason, partnering with the Indian health sector and eliciting a response from it in an attempt to improve the situation and address the current issue of overconsumption of tobacco must become an essential objective.
In addition, the issue of the health sector capacity needs to be addressed as one of the possible impediments to the TII implementation. Since active education of Indians that are currently at risk either due to smoking or due to exposure to the culture of smoking is needed, additional resources for providing consultations and maintaining active communication and connection with the target community must be utilized. According to the recent news regarding the Indian health sector, the industry has grown exponentially, having become one of the largest and most lucrative areas of business (Mishra et al., 2012). Therefore, it can be expected that the capacity of the sector will support the proposed program. At the same time, given the nature of the issue and the range of demographic that the campaign will need to embrace, it will be reasonable to consider outside sources of funding as well. Specifically, the opportunities for donations, as well as the use of investors’ support, should be examined as an option.
Finally, the issue of resources should be discussed as one of the main concerns. Although the current range of resources is quite large, there is a glaring absence of frameworks based on the use of innovative techniques and tools, particularly, the focus on social media and the power that it holds. Namely, given that the majority of the target population uses social networks actively, integrating the campaign into the social media context must be seen as a necessity. The development of media campaigns aimed at raising awareness and increasing the health literacy of Indian people who smoke or are at risk of developing the smoking habit will require exposure and extensive resources with which to supply the target population (Singh et al., 2020). Therefore, a catalog of web resources that the specified demographic will find helpful in their journey toward recovery will have to be included in the range of resources provided with the help of the TII. Additionally, a site for the target population to reach out to health experts in order to receive counseling and support must be created (Ladusingh et al., 2017). Thus, the chances to embrace as broad a range of the Indian population as possible will emerge. Furthermore, the range of resources to include in the catalog of the available tools must include materials for different ages and, therefore, has to be shaped accordingly, arranging the data according to age. Thus, children at risk of developing the habit of smoking will also be shielded from the threat.
SWOT Analysis
SWOT is one of the most widely accepted and used frameworks for project analysis. Tobacco Intervention Initiative and its main actor – the Indian Dental Association – were analyzed within the framework of SWOT to identify their strengths, weaknesses, possible threats and opportunities.
Key Findings
Situation analysis revealed a set of factors that have the greatest influence on tobacco usage in India. Tobacco usage was divided into three types – smoked tobacco, SLT, and dual usage – and for each type, the demographic and socio-economic factors were identified and measured.
Regarding people’s expectations and demands, the current trends in tobacco usage were assessed together with the attitudes and expectations of the local population. Additionally, the factors that encourage people to use tobacco and related products have been revealed. Specifically, a combination of peer pressure with the active promotion of smoking in media and the resulting early exposure of the target population to the subject matter has facilitated the epidemic scale of smoking in India (Singh et al., 2020). Counteracting the effects of the promotion campaign designed by the tobacco industry does not currently seem possible or reasonable given the fact that the specified branch of the Indian economy appears to be one of the most lucrative in the state. Therefore, minimizing its performance will not only take a tremendous amount of resources but also lead to a rise in the unemployment rates. Thus, a strategy aimed at building awareness in the target population and contributing to their understanding of the issue is required. Specifically, the target population will require access to healthcare consultations, materials, and respective services for addressing their smoking dependency.
Finally, the actions of the state and other stakeholders within the global anti-tobacco campaign were mentioned and evaluated. The research results indicate that the lack of initiative from the state has aggravated the situation, which is why further intervention is crucial (Ladusingh et al., 2017; World Health Organization, 2020). By promoting change within the target setting, one can build an environment in which people will be encouraged to accept healthy lifestyles.
Furthermore, Tobacco Intervention Initiative itself was evaluated within the framework of a SWOT analysis – its strengths, weaknesses, opportunities, and threats were listed to present a clear picture of the initiative’s status-quo and its potential perspectives. Regarding the strengths that the TII possesses, they include the uniqueness of IDA’s cessation program, and the expertise of IDA’s participants (World Health Organization, 2020). On the other hand, IDA admits that issues with reaching out to the target population are still present, which calls for further improvements.
Recommendations
Based on the summary of findings from WHO situational analysis and SWOT analysis of TII, a set of recommendations for various actors were developed. Specifically, given the current levels of tobacco product consumption in Indian people, it is highly advisable to continue addressing the situation and promoting the development of healthy habits among Indian citizens (World Health Organization, 2020). Specifically, it is recommended that a health promotion program aimed at encouraging the development of awareness in the target population should be established as the groundwork for promoting more effective management of public health issues.
The program in question will strive to increase health literacy in Indian people in order to encourage them to abandon smoking and endorse a healthy lifestyle to the target population. Specifically, the program will include the production of health information materials and resources that the target audience will find helpful in gaining key background knowledge on the issue. Additionally, the campaign will involve a foray into social media, particularly, social networks where the target population typically communicates (Kostygina et al., 2020). These will include Facebook, Instagram, and Twitter, among others. With the help of the networks in question, a massive health literacy campaign will be held as a part of TII, offering the target demographic evidence from the existing cases and peer-reviewed resources. Additionally, tools for diagnosing respiratory issues and the relevant conditions that the excessive use of tobacco products causes will be provided. Thus, every Indian citizen will be able to check their health status and receive the necessary help if needed. Finally, healthcare support tools including medications and other resources for abandoning the habit of smoking and mitigating the consequences, including problems with the respiratory system, will be offered in the TII.
The TII program will take place on the statewide level and will be implemented on the statewide level. It is believed that the program will allow bolstering the levels of health awareness in Indian people regarding the dangers of smoking, specifically, and regarding the necessity to maintain good health by leading a healthy lifestyle, in general.
Critical Reflection
Concrete Experience. The experiment involved studying the factors affecting tobacco use in India. Therefore, in the course of the study, the understanding of the culture-specific experiences of Indian consumers of tobacco, as well as the opportunity to model the actual environment of the Indian community within the TII framework, could be seen as concrete experiences that have added to the understanding of the subject matter. Namely, the ability to create a model of the target setting with the key factors affecting the participants’ choices being included was a vital experience that has expanded the range of my skills and knowledge.
Reflective Observation. Reflecting on the experience described above, I should note that its key effects included the identification of the key factors encouraging the Indian population to smoke and the evaluation of the current strategies, particularly, the problems in their implementation. Conducting the study required collecting quite a vast range of data, yet most of it pointed to the same concerns associated with health availability and the problem of awareness in the target community (Daily News and Analysis, 2016). The fact that peer pressure and social conditioning defined the decision to succumb to smoking in most Indian citizens proves that the social component must lie at the core of the further analysis and the development of an intervention (Ladusingh et al., 2017). In addition, it was highly informative to apply the process of modeling to reveal that the approximation of the observed data has helped in condensing the obtained information while retaining critical data and key variables affecting the development of smoking habits in the target population. Therefore, the process of research and the development of the TII initiative has led to an array of discoveries regarding the direction for my personal development as a researcher and the strengths and weaknesses that I must take into account when implementing the TII.
Abstract Conceptualization. The observations above have led to some important conclusions. Specifically, by considering what forces Indian people to accept the habit of smoking despite the detrimental health outcomes that it causes, one could conceptualize the obtained results based on the nature of these forces and the extent of their impact. Namely, the first concept to be addressed is the issue of peer pressure. Being the most common factor in coercing young people and children into developing the habit of smoking, it has a tremendous impact due to the instinctual need for appreciation and acceptance within a community (Singh, 2020). Therefore, I gained an important insight into the role of social factors such as the phenomenon of peer pressure in the development of the habit of smoking. The understanding of the sociocultural influences was essential to my development as a professional and the changes that were made to the program
Conceptualizing the issue further, I will need to point to the phenomenon of health literacy. Particularly, the discovery of its drastically low rates among the target demographic has inspired the idea of developing a TII program aimed at increasing the levels of health awareness and health education among Indian citizens, particularly, in regard to smoking and its adverse effects. Therefore, conceptualizing the issue further, one must connect the presence of a health threat to the problem of poor health literacy. In conjunction, the phenomenon of resource availability should be included as the next concept to be addressed. Understanding the significance of the specified concept was vital to me in determining the constituents of the health program to be implemented in the Indian setting (Gambhir et al., 2016). Specifically, it helped me to realize how nurse-patient connection can be promoted via social networks and how counseling services can be offered to customers with the help of digital technologies along with personal communication.
Active Experimentation
The concepts listed above have guided me directly to the development of the intervention plan for the smoking Indian demographic, which can be considered a prime example of active experimentation. Namely, in the course of the experimentation process, I managed to develop a new strategy for creating a communication channel for the target Indian population to use when striving to overcome the harmful habit of smoking. I realized that, based on active support and nurse-patient communication, including the option of counseling, the TII program can be considered the outcome of the active experimentation carried out in order to improve the quality of Indian people’s lives. The further stage of active experimentation will require refining the proposed approach to promoting change in the Indian healthcare context, particularly, the management of the needs of people with an addiction to smoking (Ladusingh, 2017). Nevertheless, the platform prepared so far appears to be quite functional, which is why further actions must be made in order to advance it and introduce the target population to the essentials of health management and the importance of leading a healthy lifestyle. Thus, I have made major professional and personal progress in understanding what factors shaped the success of the program aimed at helping the smoking Indian demographic to quit.
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