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  In this article
 »  Abstract
 » Introduction
 »  Materials and Me...
 » Pilot Training
 » Results
 » Discussion
 » Conclusion
 » Acknowledgement
 »  References
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  Table of Contents  
Year : 2015  |  Volume : 52  |  Issue : 4  |  Page : 685-688

Impact of modular training on tobacco control on the knowledge of health workers in two jurisdictions of northern India

1 Department of Community Medicine, School of Public Health, PGIMER, Chandigarh, India
2 Senior Technical Advisor, The Union South-East Asia, International Union Against Tuberculosis and Lung Disease, New Delhi, India

Date of Web Publication10-Mar-2016

Correspondence Address:
S Goel
Department of Community Medicine, School of Public Health, PGIMER, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-509X.178406

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 » Abstract 

BACKGROUND: National Tobacco Control Programme was launched in India in year 2007-08. It was realized that community health workers can play an important role of agents for positive change to bring down the tobacco morbidity and mortality in the country. Keeping this in view, a health worker guide was developed by the Government of India, Ministry of Health and Family Welfare (GOI) in collaboration with The Union South-East Asia (The Union) in the year 2010. The guide provides the information needed by the most basic level of health workers to effectively address the problem of tobacco use in the community. A modular training was conducted in two jurisdictions in India (namely, Chandigarh and Hamirpur (Himachal Pradesh)) to assess the usefulness of the guide as training material for community health workers in undertaking tobacco control activities at community and village levels. MATERIALS AND METHODS: A total of 271 participants were trained, which included 133 from Chandigarh and 138 from Hamirpur. The pre and post-training assessment of knowledge of health worker was done. RESULTS: There was marked increase in post-test scores as compared to the pretest scores. The health workers scoring more than 60% increased from 40% in the pretest to over 80% in the post-test. Only three workers had a post-test score of less than 30% against 54 workers in the pretest. CONCLUSION: The understanding on tobacco control had increased significantly after the training in each group. It is strongly recommended that such training should be replicated to all community health workers across all the states in India.

Keywords: Health workers, India, modular training, tobacco control

How to cite this article:
Goel S, Singh R J, Tripathy J P. Impact of modular training on tobacco control on the knowledge of health workers in two jurisdictions of northern India. Indian J Cancer 2015;52:685-8

How to cite this URL:
Goel S, Singh R J, Tripathy J P. Impact of modular training on tobacco control on the knowledge of health workers in two jurisdictions of northern India. Indian J Cancer [serial online] 2015 [cited 2020 Dec 4];52:685-8. Available from:

 » Introduction Top

Health care in India is mainly provided through the primary health care system (PHC) where primary health centres and subcentres are cornerstones of service delivery. The basic essential promotive, preventive, and curative services are provided by community health workers using community outreach programmes and facilities. Female Health Worker (FHW) or Auxiliary Nurse Midwife (ANM) and Accredited Social Health Activist (ASHA) are basic level community health worker force in India. Under India's National Rural Health Mission (NRHM), the ASHA creates awareness on health and its social determinants, mobilizes the community toward decentralized local health planning and increased utilization and accountability of existing health services and national health programmes. The male and female health worker is responsible of providing essential health services such as maternal and child health, immunization, family planning, Directly Observed Treatment (DOT), and outreach services. Apart from delivering essential health services, community health workers are also agents for health promotion in the community in which they live and work and also act as advocates for socioeconomic development and community empowerment. They have played an important role in successful implementation of various health programmes in India and are also considered important agents of positive change to bring down the tobacco morbidity and mortality in the country. Keeping this in mind, a Health Worker Guide was developed by Ministry of Health and Family Welfare and launched by the Honb'le Health Minister of India on World Health Day, 7th April 2010. This guide can be used to educate and train more than a million grass root level health care workforce in India on tobacco control.

 » Materials and Methods Top

Development of the guide

The guide, written in a simple language provides basic knowledge to community health workers on global and Indian scenario of tobacco burden; health effects of tobacco and second hand smoke; educating health workers in helping people quit tobacco and preventing young ones from initiating tobacco use and information about India's tobacco control legislation namely Cigarette and Other Tobacco Products Act (COTPA). The development of the guide was consequential to the following steps:

  • Needs assessment (formative research) among all categories of health workers, namely Accredited Social Health Activists (ASHA's), Multipurpose Health Workers (MPWs), ANMs, and nurses in rural Gurgaon, State of Haryana.
  • Peer review with experts in State of Orissa.
  • Field testing among health workers in Ranchi, Jharkhand.
  • Finalization with inputs from tobacco experts and key stakeholders.

The guide provides the information needed by the most basic level of health workers to address the tobacco use problem in the communities.

Pre-testing the guide

The guide was also pretested to enable the trainers to judge the best method of using the manual in training the health workers. The pre-testing was done among two batches of health workers: One each of ASHAs and DOTS providers serving the Department of Health, Government of Delhi, India. The pre-testing yielded the following recommendations:

  • The training on tobacco control should be conducted for health workers assuming their level of knowledge on the subject is very low.
  • The 'modular pattern' was preferred by health workers as compared to the 'lecture pattern'. The time allocated for training ought to be minimum 2 h.
  • Smaller groups are better than larger ones because it is extremely important that each member of the group participates to get his queries answered.

 » Pilot Training Top

To ensure that all states adopt the Health Worker Guide (HWG) to train health workers at the grass root level, a pilot training was proposed incorporating the recommendations proposed above.

The training was planned after discussion with the stakeholders in the states of Himachal Pradesh, Rajasthan, Chandigarh, Delhi, Gujarat, and Tamil Nadu. These states were shortlisted for this training keeping in view the feasibility and state government's willingness. Following this, training centres and Master Trainers were identified. The master trainers contributed to the development of the guide and consisted of State and district tobacco control officers, Tobacco experts from Schools of Public Health, PGIMER, Chandigarh, India, and consultants from The Union. The overall purpose of this training was to assess the usefulness of the guide as a basic guide to train the health workers for undertaking tobacco control activities at community and village levels. As a part of the exercise, finally health workers in Hamirpur and Chandigarh were trained using the English version of the the Guide as planned in [Table 1].
Table 1: Details of the training in two cities

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Description of the training

This 3-h course was delivered as two sessions of one hour each and one half-an-hour session of open discussion and comments. The remaining 30 min featured pretest at the beginning of the first session and post-test at the end of the last. The methodology of the training was 'modular teaching', that is, reading of the module by the participants followed by participatory discussion.

Pre- and Post-test training evaluation

A pre- and post-training questionnaire was administrated to the training participants before and after the training and given 15 min to complete each. The detailed results of evaluation are shown in [Figure 1]a and [Figure 1]b.
Figure 1: (a) Evaluation of health workers training on tobacco control at Hamirpur. (b) Evaluation of health workers training on tobacco control at Chandigarh

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 » Results Top

The results showed that there was marked increase in knowledge scores from post-test results when compared with those of pretest results. Only three workers had the post-test score of less than 30% against 54 workers in pretest. The mean pretest scores at Hamirpur and Chandigarh were 9.0 (S.D.3.3) and 8.4 (S.D.2.5), respectively, whereas the mean post-test scores were 12.9 (S.D.1.5) and 12.6 (S.D.1.9), respectively. There was significant difference (P < 0.05) between the mean pre- and post-test scores at both the centres. Overall the difference between the pre and post scores at both the centres combined was also found to be significant (P < 0.05). The health workers were tested on four major domains namely tobacco health statistics, health effects of tobacco, antitobacco laws and perceived role of health workers in tobacco control. Pre–post evaluation in both the centres found significant gain in knowledge in all the four domains (P < 0.001).

 » Discussion Top

The International Union Against Tuberculosis and Lung Disease (The Union)) opines that technical tobacco control training for policymakers, NGOs, opinion leaders, physicians, and other stakeholders can have far reaching impact in reducing tobacco-related morbidity and mortality.[1] But the role of trained community level workers in tobacco control is largely unexplored.

There is an ample evidence that health worker numbers and quality are strongly associated with the success of many programs and positive health outcomes such as good immunization coverage; outreach of primary care; and infant, child, and maternal survival.[2],[3] Community Health Workers (CHWs) have demonstrated appreciable impact on Millennium Development Goals 4, 5, and 6, that is, reduce child mortality, improve maternal health, and combat HIV/AIDS, malaria, and other diseases.[4] The mental health training program of PHC workers proved the hypothesis that training of health workers along with supervision would result in change in knowledge and practical clinical skills which can be replicated and adopted for use in resource-poor settings.[5] The Mental Health Program in India also focuses on community-based approach through training of medical and other paramedical staff including MPWs. Many studies have documented that the performance of primary health care workers with respect to the diagnosis and treatment of specific childhood diseases does improve after IMCI training.[6],[7],[8],[9],[10] Training workshops in TB control proved effective for promotion of knowledge and elimination of stigmatization in primary caregivers including DOT providers.[11] More than 80% of the participants were of the opinion that the trainings provided under NACP increased their practical skills and efficiency.[12]

Thus, the role of trained primary level health workers in ensuring equitable distribution of basic essential health services has been proved time and again. CHWs have notably proven crucial in resource-poor settings. They represent a strategic solution to address the shortage of highly skilled health workers and the growing demand of the ever inflating population. The current health care reform environment presents a valuable opportunity to acknowledge and capitalize on the huge community health manforce.[13] However, training is an important aspect of any successful program. Inadequate training is a common weakness. Thus, the need to systematically and professionally train lay community members to be a part of the health workforce has emerged as a core component of primary health care systems in low-resource settings.[4]

To sustain tobacco control initiatives in India, Samet felt that there are immediate and long-term needs for capacity development in India.[14] Many studies have emphasized the role of health professionals in sustaining tobacco control initiatives. VHAI in its report also recommended the inclusion of tobacco-related concerns in the curriculum of medical students, nurses, and other health care providers.[15] But the focus until now has revolved around creating a core group of trained doctors, public health specialists, and other experts to carry forward the baton of tobacco control for decades to come. But in a resource-poor demand-rich setting like India, depending on doctors and nurses alone to provide universal services is not a feasible option. Therefore, the community workers need to be roped in to hold the fort of tobacco control efforts.

The participants of the Regional Workshop on the MPOWER Policy Package for Strengthening Tobacco Control held in Dhaka in April 2009 also agreed upon providing tobacco cessation services through primary health-care settings and community-based interventions, as well as providing necessary training to health workers on tobacco control.[16]

Thus, the role of trained community health workers in implementing tobacco control policies in India can be very crucial in curbing the tobacco epidemic. In this study, we look at the pilot trainings imparted to grass root level health workers on tobacco control at two centres in India. This was the first of its kind because it was the first ever attempt to try and involve health workers in a tobacco related program in India through formal training. Therefore, it is all the more important to evaluate the training methodology and impact so that poor training capacity does not hinder the success of the program in the long run.

The training feedback revealed that participants at Hamirpur had difficulty in reading and understanding English version of the module but at Chandigarh they could read and understood it well without any difficulty. The health workers at Hamirpur and local co-faculty felt that any further training should be done using Hindi version. The participants were of the opinion that the guide is quite comprehensive and content is very simple to understand. The adequate time for reading and open discussion in either morning or evening sessions was found to be 3 h. To increase involvement of all participants, each batch should have 25-30 participants.

This study also showed that there was marked increase in scores from post-test results when compared with those of pre-test results, which demonstrate that understanding on tobacco control had increased after the training was imparted in each group. The health workers scoring more than 60% increased from 40% in pretest to over 80% in post-test. Their knowledge gain regarding tobacco health statistics, health effects of tobacco, antitobacco laws and perceived role of health workers in tobacco control post-training was highly significant in both the centres (P < 0.001) [

[Figure 2]a and [Figure 2]b. Sheffer et al. also demonstrated significant increase in knowledge, attitude, and behaviour toward tobacco treatment and dependence. All professionals namely physicians, nurses, dentists, and other health-related professionals reported significantly more knowledge and more positive attitudes on nearly all measures.[17] Comprehensive evaluation of an online tobacco course showed significant results post-training. The online course had three modules namely cessation, prevention, and protection and covered topics like epidemiology of tobacco use, anti-tobacco programs and policies.[18] Thus, improving the training curriculum with modules on tobacco cessation and dependence can be a viable option. On a final note, effective training for community health workers can go a long way in providing sustainability to the tobacco control efforts in the battle against this emerging epidemic.
Figure 2: (a) Training at Hamirpur, comparison of pre- and post-test scores. (b) Training at Chandigarh, comparison of pre- post-test scores

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 » Conclusion Top

Health Workers have an important role to play in educating the communities on harmful effects of tobacco and helping them quit tobacco use. It is high time that National Tobacco Control Programme in collaboration with NRHM should take it forward and ensure training of over million health workforce in India. To accomplish this, the guide needs to be translated in various Indian languages. Further, training of trainers should be accelerated in collaboration under the banner of NRHM so as to decentralize the training process. This course if extended throughout the country could have a profound public health impact.

 » Acknowledgement Top

We greatly acknowledge support from MOH and FW, Government of India and Bloomberg Initiative to Reduce Tobacco Use for development of Health Worker guide and to undertake training at Hamirpur and Chandigarh. We also acknowledge support from Departments of Health and Family Welfare of states of Himachal Pradesh and Chandigarh for supporting training at two jurisdictions.

 » References Top

WHO: The world health report 2006: Working together for health. Geneva: World Health Organization; 2006.  Back to cited text no. 2
Lewin S, Munabi-Babigumira S, Glenton C, Daniels K, Bosch-Capblanch X, van Wyk BE, et al. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database Syst Rev2010;3:CD004015.  Back to cited text no. 3
One Million Community Health Workers: Technical Task Force Report. New York: Earth Institute, Columbia University; 2011  Back to cited text no. 4
Budosan B, Jones L. Evaluation of effectiveness of mental health training program for primary health care staff in Hambantota District, Sri Lanka post-tsunami. Journal of Humanitarian Assistance Published online 2009 May 1. Available from: [Last accessed 21.12.12].  Back to cited text no. 5
Amorim DG, Adam T, Amaral JJ, Gouws E, Bryce J, Victora CG. Integrated Management of Childhood Illness: Efficiency of primary health in Northeast Brazil. Rev Saude Publica 2008;42:183-90.  Back to cited text no. 6
Kumar D, Aggarwal AK, Kumar R. The effect of interrupted 5-day training on Integrated Management of Neonatal and Childhood Illness on the knowledge and skills of primary health care workers. Health Policy Plan 2009;24:94-100.  Back to cited text no. 7
Chaudhary N, Mohanty PN, Sharma M. Integrated management of childhood illness (IMCI) follow up of basic health workers. Indian J Pediatr 2005;72:735-9.  Back to cited text no. 8
Kalter HD, Schillinger JA, Hossain M, Burnham G, Saha S, de Wit V, et al. Identifying sick children requiring referral to hospital in Bangladesh. Bull World Health Organ 1997;75 Suppl 1:65-75.  Back to cited text no. 9
Health worker performance after training in integrated management of childhood illness-Western Province, Kenya, 1996-1997. MMWR Morb Mortal Wkly Rep 1998;47:998-1001.  Back to cited text no. 10
Wu PS, Chou P, Chang NT, Sun WJ, Kuo HS. Assessment of changes in knowledge and stigmatization following tuberculosis training workshops in Taiwan. J Formos Med Assoc 2009;108:377-85.  Back to cited text no. 11
Witmer A, Seifer SD, Finocchio L, Leslie J, O'Neil EH. Community health workers: Integral members of the health care work force. Am J Public Health 1995;85:1055-8.  Back to cited text no. 13
Samet JM, Wipfli H. Building tobacco control training capacity in India. Curr Sci 2009;96;1315-8.  Back to cited text no. 14
Nath LM, Lobo J. Tobacco Control and the Training of Health Care Providers. New Delhi: Voluntary Health Association of India; 2010.  Back to cited text no. 15
Effective Implementation of the WHO Framework Convention on Tobacco Control through the MPOWER Policy Package. Geneva: World Health Organization; 2009.  Back to cited text no. 16
Sheffer CE, Barone CP, Anders ME. Training health care providers in the treatment of tobacco use and dependence: Pre- and post-training results. J Eval Clin Pract 2009;15:607-13.  Back to cited text no. 17
Sears KE, Cohen JE, Drope J. Comprehensive Evaluation of an Online Tobacco Control Continuing Education Course in Canada. J Contin Educ Health Prof 2008;28:235-40.  Back to cited text no. 18


  [Figure 1], [Figure 2]

  [Table 1]


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