Manu Raj Mathur

Factors determining intention to quit tobacco: exploring patient responses visiting public health facilities in India

IntroductionIntention to quit and setting a quit date are key steps in the process towards improving quit rates and are thus an integral part of tobacco cessation efforts. The present study examined various motivating factors of “intention to quit” and “setting a quit date” in patients visiting public health facilities in two states of India.MethodsA total of 1569 tobacco-users visiting public health facilities in 12 districts of the states of Andhra Pradesh and Gujarat were assessed through an interviewer-administered questionnaire. Bivariate and multivariable logistic regression was performed to assess the effect of socio-demographic characteristics, nicotine dependence, previous quit attempts and motivational factors on “intention to quit within 30 days” and “setting a quit date”.ResultsOnly 12% of patients intended to quit tobacco within 30 days and about 11% of them were ready to set a quit date. Respondents aged above 25 years were 53% less likely to quit tobacco within 30 days when compared to those below 25 years (95% Confidence Intervals [CI]: 0.22 to 0.99). Smokeless tobacco users were associated with an odds ratio (OR) of 2.05 (95% CI: 1.15 to 3.65) for “setting a quit date” when compared to smokers. Those with 1 to 5 previous quit attempts (in the past twelve months) were associated with an OR of 2.2 (95% CI: 1.38 to 3.51) for “intention to quit” and 2.46 (95% CI: 1.52 to 3.96) for “setting a quit date”. “Concern for personal health” and “setting an example for children” were associated with ORs of 3.42 (95% CI: 1.35 to 8.65) and 2.5 (95% CI: 1.03 to 6.03) respectively for “setting a quit date”.ConclusionsThis study is amongst the first in India to explore factors associated with the “intention to quit” and “setting a quit date” among patients visiting public health facilities. Our findings suggest that socio-economic and individual-level factors are important factors depicting intention to quit and setting a quit date. We recommend the need for well-defined studies to understand the long term effects of factors influencing tobacco cessation for patients visiting public health facilities in India.

Socioeconomic inequalities in dental caries and their determinants in adolescents in New Delhi, India

Objectives To determine whether socioeconomic inequalities are correlated to dental caries experience and decayed teeth of Indian adolescents, and assess whether behavioural and psychosocial factors mediate this association. Methods Cross-sectional study of 1386 adolescents living in three diverse areas of New Delhi. Caries experience and number of decayed teeth were assessed clinically and a questionnaire was used to gather sociodemographic and psychosocial data. Zero Inflated Negative Binomial regression models were used to assess the relationship between the outcomes (caries experience and decayed teeth) and area of residence, adjusting for covariates. Results Significant inequalities in caries experience and number of decayed teeth were observed. Odds of an adolescent being caries free decreased by 66% (OR 0.34, 95% CI 0.23 to 0.49) and 70% (OR 0.30, 95% CI 0.21 to 0.43) in adolescents living in resettlement communities or urban slums, respectively, when compared with the middle class group. No difference was observed among those with caries experience/decayed teeth. Adjusting for covariates did not affect the inequalities. Conclusions Area of residence appears to be a very strong and significant determinant for an adolescent to be caries/decay free in India. Psychosocial and behavioural factors do not mediate the association between area of residence and oral health.

Scientific evidence on the links between periodontal diseases and diabetes: Consensus report and guidelines of the joint workshop on periodontal diseases and diabetes by the International Diabetes Federation and the European Federation of Periodontology

BACKGROUND Diabetes and periodontitis are chronic non-communicable diseases independently associated with mortality and have a bi-directional relationship. AIMS To update the evidence for their epidemiological and mechanistic associations and re-examine the impact of effective periodontal therapy upon metabolic control (glycated hemoglobin, HbA1C). EPIDEMIOLOGY There is strong evidence that people with periodontitis have elevated risk for dysglycemia and insulin resistance. Cohort studies among people with diabetes demonstrate significantly higher HbA1C levels in periodontitis patients (vs. periodontally healthy), but there is insufficient data among people with type 1 diabetes. Periodontitis is also associated with an increased risk of incident type 2 diabetes. MECHANISMS Mechanistic links between periodontitis and diabetes involve elevations in interleukin (IL) 1-β, tumor necrosis factor-α, IL-6, receptor activator of nuclear factor-kappa B ligand/osteoprotegerin ratio, oxidative stress and toll-like receptor (TLR)2/4 expression. INTERVENTIONS periodontal therapy is safe and effective in people with diabetes and it is associated with reductions in HbA1C of 0.27-0.48% after 3-months, although studies involving longer-term follow up are inconclusive. CONCLUSIONS European Federation of Periodontology (EFP) and the International Diabetes Federation (IDF) report consensus guidelines for physicians, oral health care professionals and patients in order to improve early diagnosis, prevention and co-management of diabetes and periodontitis. This article is protected by copyright. All rights reserved.

A Framework to Prevent and Control Tobacco among Adolescents and Children: Introducing the IMPACT Model

The objective of this paper is to provide a comprehensive evidence based model aimed at addressing multi-level risk factors influencing tobacco use among children and adolescents with multi-level policy and programmatic approaches in India. Evidences around effectiveness of policy and program interventions from developed and developing countries were reviewed using Pubmed, Scopus, Google Scholar and Ovid databases. This evidence was then categorized under three broad approaches: Policy level approaches (increased taxation on tobacco products, smoke-free laws in public places and work places, effective health warnings, prohibiting tobacco advertising, promotions and sponsorships, and restricting access to minors); Community level approaches (school health programs, mass media campaigns, community based interventions, promoting tobacco free norms) and Individual level approaches (promoting cessation in various settings). This review of literature around determinants and interventions was organized into developing the IMPACT framework. The paper further presents a comparative analysis of tobacco control interventions in India vis a vis the proposed approaches. Mixed results were found for prevention and control efforts targeting youth. However, this article suggests a number of intervention strategies that have shown to be effective. Implementing these interventions in a coordinated way will provide potential synergies across interventions. Pediatricians have prominent role in advocating and implementing the IMPACT framework in countries aiming to prevent and control tobacco use among adolescents and children.

Perception and practices of physicians in addressing the smokeless tobacco epidemic: findings from two States in India.

BACKGROUND Smokeless tobacco use in South Asia is believed to be a significant contributor to morbidity and mortality. In India, only a few studies involving health educational intervention by health care providers have demonstrated reduction in smokeless tobacco usage. In the present study we assessed the cessation efforts towards smokeless tobacco by physicians in two high tobacco prevalence states of India. The study also identified opportunities and barriers for integration of tobacco cessation services in routine practices of physicians. MATERIALS AND METHODS This mixed method study involved qualitative (phase I) and quantitative research study (phase II). In phase I, 59 in-depth interviews with physicians were conducted. In phase II, a quantitative study conducted among 238 physicians. An inductive approach was followed to analyze qualitative data using ATLAS. Ti software. The Chi-square test was employed to test the association between different variables of interest using SPSS version 17. RESULTS The majority of physicians related only respiratory problems and cancer with smokeless tobacco. Other major health effects like cardio-vascular problems, oral diseases, and effects on reproductive and neonatal health were recognized only by a few physicians. The age-group of 10-19 years was identified as most vulnerable to smokeless tobacco use. Less than one-third of physicians reported recording smokeless tobacco history of all patients. Findings indicated that less than half of physicians provided information on harmful health effects of smokeless tobacco with regard to specific diseases. CONCLUSIONS The study revealed a low level of knowledge of physicians about harmful effects of tobacco and their suboptimal engagement in tobacco control practices. The study indicates the need of capacity building initiatives to equip physicians with skills in tobacco cessation.

Addressing inequalities in oral health in India: need for skill mix in the dental workforce

Dentistry has always been an under-resourced profession. There are three main issues that dentistry is facing in the modern era. Firstly, how to rectify the widely acknowledged geographical imbalance in the demand and supply of dental personnel, secondly, how to provide access to primary dental care to maximum number of people, and thirdly, how to achieve both of these aims within the financial restraints imposed by the central and state governments. The trends of oral diseases have changed significantly in the last 20 years. The two of the most common oral diseases that affect a majority of the population worldwide, namely dental caries and periodontitis, have been proved to be entirely preventable. Even for life-threatening oral diseases like oral cancer, the best possible available treatment is prevention. There is a growing consensus that appropriate skill mix can prove very beneficial in providing these preventive dental care services to the public and aid in achieving the goal of universal oral health coverage. Professions complementary to dentistry (PCD) have been found to be effective in reducing inequalities in oral health, improving access and spreading the messages of health promotion across entire spectrum of socio-economic hierarchy in various studies conducted globally. This commentary provides a review of the effectiveness of skill mix in dentistry and a reflection on how this can be beneficial in achieving universal oral health care in India.

Scientific evidence on the links between periodontal diseases and diabetes: Consensus report and guidelines of the joint workshop on periodontal diseases and diabetes by the International diabetes Federation and the European Federation of Periodontology

BACKGROUND Diabetes and periodontitis are chronic non-communicable diseases independently associated with mortality and have a bidirectional relationship. AIMS To update the evidence for their epidemiological and mechanistic associations and re-examine the impact of effective periodontal therapy upon metabolic control (glycated haemoglobin, HbA1C). EPIDEMIOLOGY There is strong evidence that people with periodontitis have elevated risk for dysglycaemia and insulin resistance. Cohort studies among people with diabetes demonstrate significantly higher HbA1C levels in patients with periodontitis (versus periodontally healthy patients), but there are insufficient data among people with type 1 diabetes. Periodontitis is also associated with an increased risk of incident type 2 diabetes. MECHANISMS Mechanistic links between periodontitis and diabetes involve elevations in interleukin (IL)-1-β, tumour necrosis factor-α, IL-6, receptor activator of nuclear factor-kappa B ligand/osteoprotegerin ratio, oxidative stress and Toll-like receptor (TLR) 2/4 expression. INTERVENTIONS Periodontal therapy is safe and effective in people with diabetes, and it is associated with reductions in HbA1C of 0.27-0.48% after 3 months, although studies involving longer-term follow-up are inconclusive. CONCLUSIONS The European Federation of Periodontology (EFP) and the International Diabetes Federation (IDF) report consensus guidelines for physicians, oral healthcare professionals and patients to improve early diagnosis, prevention and comanagement of diabetes and periodontitis.

Determinants of Socioeconomic Inequalities in Traumatic Dental Injuries among Urban Indian Adolescents

Objectives To assess socioeconomic inequalities in traumatic dental injuries (TDIs) in adolescents in New Delhi and examine the role of material, psychosocial and behavioural factors in explaining these inequalities. Methods We conducted a cross sectional study of 1386 adolescents aged between 12–15 years residing in three diverse areas of New Delhi. A non-invasive clinical examination was used to estimate the prevalence of TDIs, and an interviewer-administered questionnaire was used to gather relevant behavioural and socio-demographic data. Multiple logistic regression models were used to assess the association between area based socioeconomic position and TDIs. Results The overall prevalence of TDIs was 10.9%. Social inequalities in the prevalence of TDIs were observed across the adolescent population according to their area of residence. Socio-economic group differences in the prevalence of TDIs remained statistically significant after adjusting for demographic factors, material resources, social capital, social support and health affecting behaviours (OR 3.36, 95% CI 1.75–6.46 and OR 3.99, 95% CI 1.86–8.56 for adolescents from resettlement areas and urban slums respectively in comparison to middle class adolescents). Different psychosocial, material and socio-demographic variables did not attenuate the estimates for the relationship between area socioeconomic position and TDIs. Conclusion Area of residence was a strong predictor of TDIs in adolescents with a higher prevalence in more deprived areas. Social inequalities in TDIs were not explained by psychosocial and behavioural variables. Health promoting policies aimed at improving the physical environment in which adolescents reside might be instrumental in reducing the prevalence of TDIs and associated inequalities.

Universal Health Coverage A Unique Policy Opportunity for Oral Health

The United Nations (UN) Millennium Development Goals (MDGs) will end in 2015 and will be replaced by Sustainable Development Goals (SDGs). The MDGs were successful in bringing national governments together and highlighted the importance of health in human development. However, the MDGs had a very specific disease focus, did not incorporate noncommunicable diseases (NCDs), and failed to have a significant effect on reducing health inequalities within and between countries (Save the Children 2012; UNSDSN 2013). The new SDGs will provide a framework for integrating action across multiple sectors to enable human development to proceed in a manner that optimizes the use of limited resources without endangering sustainability. In recent months, consultations and high-level panel meetings have deliberated on how health can be included in the SDGs and what would be appropriate indicators for any new global health goal(s) (Save the Children 2012; United Nations 2013; UNSDSN 2013). One common theme emerging from these consultations is universal health coverage (UHC), either as a specific health goal or as a means of achieving health gains in the post-2015 SDGs. The call for UHC has grown stronger over the past decade. The Rio +20 summit on sustainable development recognized UHC for enhancing “health, social cohesion and sustainable human and economic development and a precursor to strengthen national health systems” (United Nations 2012). Dr Margaret Chan, the director general of World Health Organization (WHO), has called UHC the “the single most powerful concept that public health has to offer” (Holmes 2012), and Dr Jim Yong Kim, the president of the World Bank, has called for the global achievement of UHC “within this generation” (World Bank 2013). A unique opportunity currently exists to influence global health policy and ensure that oral health is recognized as a key public health priority and is integrated into the emerging UHC policy agenda.

Association between tooth loss and hypertension among a primarily rural middle aged and older Indian adult population

BACKGROUND Studies in high-income countries have reported associations between tooth loss and hypertension. There is however a lack of evidence on this association from South Asian countries especially India. The current study aimed to assess the association between self-reported tooth loss and hypertension in a primarily rural middle-aged and older Indian population. METHODS A secondary analysis of cross-sectional data from the Longitudinal Ageing Study of India - pilot survey was conducted on 1,486 adults aged 45 years and above from four states of India. The primary outcome was self-reported hypertension and the main explanatory variable was self-reported tooth loss. Multivariable logistic regression models estimated the association between hypertension and tooth loss after controlling for confounders including age, sex, marital status, area of residence, educational attainment, tobacco use, alcohol use, physical activity, and self-reported diabetes. RESULTS Compared to those without any tooth loss, individuals with partial tooth loss had 1.62 times (95% CI: 1.12-2.35) higher odds of being hypertensive after adjustment of confounders including age, sex, marital status, area of residence, educational attainment, tobacco use, alcohol use, physical activity, and self-reported diabetes. The crude significant association (OR: 2.54; 95% CI: 1.50-4.29) between edentulousness and hypertension became nonsignificant and attenuated after adjustment of potential confounders (fully adjusted model OR: 1.33; 95% CI: 0.72-2.44). CONCLUSION Partial tooth loss was associated with a higher probability of hypertension among dentate middle-aged and older adults in four states of India.