Developing a smartphone-based training strategy for tobacco control in India: a formative study using consolidated framework for implementation research

INTRODUCTION

Tobacco use is the single most avoidable cause of premature death, causing over 8 million deaths per year. About 80% of the world’s 1.3 billion tobacco users live in low and middle-income countries (LMICs).¹ Study teams from India and the U. S. (referred to as the study team) developed and tested TFT-TFS, a school-based tobacco control intervention, in a cluster-randomized study in Bihar, India.^2-6 We structured the program around six monthly themes, engaging both users and non-users by positioning teachers as role models. It aimed to help tobacco users quit, provide teachers with knowledge and skills to support others in quitting tobacco, and implement school tobacco control policies. Results showed a 50% cessation rate in intervention schools versus 15% in control schools.² The success of any EBI like TFT-TFS depends on the training of the implementers. However, in-person training poses challenges, including time and resource demands, logistical issues, and variations in trainer communication and expertise, potentially compromising content fidelity at scale.^7-10 Smartphone-based training can overcome these barriers by replacing didactic lectures with flexible, asynchronous learning.¹¹ This prompted the development of a smartphone-based training strategy for implementing the TFT-TFS program in schools, enabling faster outreach to more trainees, particularly in under-resourced areas with high tobacco use. We will test this smartphone-based training strategy in MP, India, to scale up the TFT-TFS program. This paper assesses contextual factors before developing a smartphone-based training strategy for TFT-TFS implementers in MP, India, using the CFIR.^12,13

METHODS

An exploratory formative study was conducted to assess the feasibility of developing a smartphone-based training strategy for school principals and teachers (referred to as participants) to train principals to implement the TFT-TFS program in their schools among teachers. The objectives were to explore the facilitators and barriers of ongoing tobacco control activities in schools, understand participants' smartphone usage patterns, technological familiarity, awareness and perceptions of gamification and other game mechanics, and determine how to develop a smartphone-based training strategy to train principals to implement TFT-TFS program in their schools among teachers to achieve better implementation outcomes. CFIR, a determinant and an explanatory framework was used to understand “what works where and why in multiple contexts”.^13-15 The four CFIR domains from the CFIR 2.0 guided the questions for the formative study, which are defined as:¹²

Innovation

The duration of smartphone-based training for implementing the TFT-TFS program, time and scope of orienting the principals on the smartphone-based training, design quality/packaging of TFT-TFS components, and complexity in the interactive smartphone-based training strategy.

Inner setting

Alignment of the TFT-TFS program with the schools’ processes and tobacco control efforts.

Outer setting

Needs and resources related to tobacco control and leadership support for successful TFT-TFS training and implementation

Individuals

Participants’ knowledge and beliefs about the need for effective implementation of the TFT-TFS program.

This study is a collaboration between the Healis Sekhsaria institute for public health in Mumbai, India, the Dana-Farber cancer institute and the Harvard T.H. Chan school of public health, USA; the department of education (DoE) MP and local state partner MP voluntary health association (MPVHA), Indore, India.

Study design

We used qualitative methods comprising-KIIs with principals, FGDs with school teachers; and direct school observations. We selected these three methods to triangulate the data points, enhancing the depth and reliability of our understanding of the context in which the TFT-TFS program’s smartphone-based training and implementation will occur. We got permission from the MP State DoE and district-level officials to allow schools to participate in this study. The Harvard T.H. Chan school of public health’s office of regulatory affairs and research compliance and the Healis-Sekhsaria institute for public health’s institutional ethics committee approved all study procedures.

Study setting

MP is India’s second-largest state, with approximately 72 million people in 2011.¹⁶ We chose four districts comprising rural, urban, and tribal populations that had high tobacco use prevalence (over 33%).¹⁷ For the formative study, we visited 36 schools across four districts, where principals were the head authority. We conducted 17 KIIs with principals (15 males, 2 females) as potential TFT-TFS implementers in their schools. Additionally, we interviewed a DoE-the administrative authority of his district for educational activities.

Data collection

We conducted 14 FGDs with male and female teachers (group size ranges between 3-22 teachers), as they are the recipients of the TFT-TFS program. We conducted all FGDs and KIIs in Hindi. They were audio recorded after obtaining consent from participants, moderated by trained staff, and assisted by a trained note-taker. We conducted each FGD for 20-30 minutes in June-July and November 2022. Participants ranged in age from 27 to 60 years.

In addition, we visited 36 schools during 2022 (June-July and November) and 2023 (January). We observed the presence of tobacco control signs and policy, spit marks, stains, and wrappers from chewing tobacco; leftover ashes, cigarette/bidi butts, and discarded packages of smoking tobacco; any shops or kiosks selling tobacco within 100 yards of the schools, electricity; wi-fi; mobile network coverage using a standardized and pre-tested checklist.³

Data analysis

The data were analyzed following a five-step iterative process (Figure 1) of the framework analysis.^18-21 (i) Two trained staff from the India team independently transcribed all FGDs and KIIs verbatim in Hindi and then translated them into English. One researcher from the India team (the lead author) independently listened to the audio recordings and matched them with the transcripts and translations to familiarize herself with the data. (ii) She then analyzed the transcripts using qualitative content analysis, a deductive-directed approach, and identified initial themes. (iii) She indexed codes relevant to CFIR in the transcripts. (iv) She charted the transcripts into themes in excel. (v) The study team repeatedly reviewed the codes and transcripts, matching them to the CFIR domains to ensure appropriate interpretation.²¹

RESULTS

Facilitators and barriers based on CFIR domains

Figure 2 outlines positive influences that were more likely to act as facilitators and negative influences that were more likely to create barriers in the TFT-TFS program training and implementation.

Relevant quotes were categorized thematically as facilitators or barriers and mapped them to four CFIR domains in Table 1.

Innovation domain

Three (Relative advantage, adaptability, and design) out of eight Innovation constructs emerged from the study. The three constructs acted as facilitators, while only the design construct presented a barrier.¹²

Relative advantage

Participants reported shorter videos, ranging from 10 to 15 minutes, as helpful for training to implement the TFT-TFS program in their schools. They also recommended incorporating quizzes after each video to assess their learning.

Adaptability

In Indian society, successful kite flying requires skill and symbolizes communal harmony, achievement, and freedom. Participants recommended using the kite-flying concept as of leaderboards to resonate as a positive and culturally relevant influence to foster fun and healthy competition among schools while implementing the TFT-TFS program. They also noted that their previous educational apps, like Diksha and m-Shiksha, showed progress bars after uploading photos of each completed activity, motivating them to complete training.

Design

The widespread use of Android smartphones, training, and apps, especially during COVID-19, positively influenced receiving TFT-TFS training through a smartphone-based Android app. Most participants had basic smartphones with older Android versions and limited mobile space with existing apps for professional and personal use. They preferred an app that would be easy to navigate, consuming less mobile space and data while installing and operating it. They recommended using push notifications, similar to those in shopping apps, to remind them of monthly activities in the TFT-TFS app and enhance engagement.

Outer setting domain

Three (Critical incidents, local conditions, policies and laws) out of ten outer setting constructs emerged under this domain.¹² The local conditions and policies and laws had both positive and negative influences, while critical incidents had only negative influences.

Critical incidents

Participants perceived other administrative tasks like training, elections, and the census duties as barriers to smartphone-based TFT-TFS training, overburdening them and distracting from teaching. However, a KII with the district collector (administrative official) revealed that elections happen every three years, census happen every ten years, and not all teachers participate in every program, suggesting that other administrative tasks may not be significantly hinder smartphone-based TFT-TFS training and implementation.

Local conditions

The ‘clean India mission’ (government cleanliness campaign) was a facilitator for the TFT-TFS program, aligning with its goal of maintaining tobacco-free schools.²² In addition, participants’ familiarity with WhatsApp, Google forms, and Zoom also supported the TFT-TFS smartphone-based training. School observations confirmed these findings. They also reflected that all schools had electricity but no Wi-Fi connections, with teachers using personal mobile data for routine activities.

A few key barriers included the widespread consumption of smokeless tobacco (SLT) as pouches (branded sachet of flavored mouth fresheners supplemented with a transparent, not-branded/not labeled sachet containing tobacco to be mixed with the mouth freshener before consumption) among teachers and endorsements of pan masalas (blend of betel nut/areca nut, and other aromatic flavors like cardamom seeds, cloves, sandalwood oil, and catechu) by celebrities through the advertisements. These advertisements do not depict tobacco in pan masalas, as it is provided separately in a complimentary packet, similar to those given with pouches at shops or kiosks. They only give these complimentary tobacco packets to known customers or those who ask for them. Participants argued it becomes difficult for parents and teachers to teach the young generation not to consume those products as the young generation considers those celebrities as ‘ideals’.

School observations revealed only one of 36 schools had a ‘No Smoking’ sign, while 16 had visible spit marks, stainings, and wrappers from chewing tobacco; leftover ashes, butts, and discarded packages from smoking tobacco. Additionally, high alcohol consumption in rural and tribal areas was a challenge to the smartphone-based TFT-TFS training and implementation, perceiving tobacco as a low priority.

Policies and laws

Participants viewed tobacco free educational institutions (ToFEI) the 9-point government-initiated tobacco-control program as a facilitator under this construct.²³ Few schools complied with only one of the nine points: ‘No sale and purchase of tobacco within 100 yards of educational institutions.

Further, the participants responded that web series content shown on any of the ‘over the top’ (OTT) platforms is becoming popular in the Indian context, which has no statutory warnings on the harmful effects of tobacco and alcohol use. They believed it was negatively influencing ongoing tobacco control activities and would act as a perceived barrier to implementing the TFT-TFS program.

Inner setting domain

Five (Communications, mission alignment, culture (Recipient-centeredness), incentive systems, and compatibility) out of 11 inner setting constructs emerged under this domain. All five constructs are found as facilitators.¹²

Communications

Participants opined the strong communication network within school WhatsApp groups, connecting districts, blocks, principals, and teachers as a facilitator.

Official communication, whether through WhatsApp or hard copy letters, holds significant value, especially when sent from higher authorities to school principals. Participants indicated that permission letters from DEOs or District Collectors would facilitate the smartphone-based TFT-TFS training and implementation.

Mission alignment

Participants perceived posters within the school premises depicting ‘No sale or purchase of tobacco products within 100 yards’ (one of the 9 points from the ToFEI guidelines) and government cleanliness campaigns as facilitators.^22,23

Furthermore, the schools’ existing system of holding rallies, events, or cleaning entire school grounds on special occasions like India’s Independence Day (August 15^th), the birthdays of national heroes like Mahatma Gandhi (October 2^nd), Pandit Jawaharlal Nehru (November 14^th), or the teachers’ day (September 5^th), etc., are perceived as positive influencers in the promoting and implementing tobacco control programs in schools.

Culture (Recipient-centeredness)

Participants reported the sub-construct recipient-centeredness under the construct of culture as a facilitator. Participants from almost all schools commented that about 30% of the population are tobacco users within the community and in other schools of the block; however, no teachers in their schools consume tobacco during school hours.

Hence, they perceived that the TFT-TFS might be a suitable program addressing the needs and welfare of the teachers from other schools where the tobacco problem is high.

Incentive systems

Participants recognized tangible rewards and incentives, such as certification, as facilitators for the training and implementation of the smartphone-based TFT-TFS program. They believed that awarding certificates to top-performing schools and implementers by the district officials or the study team after implementing of the TFT-TFS program would further motivate and encourage participation in the smartphone-based training and implementation.

Compatibility

We defined compatibility as how the TFT-TFS smartphone-based training and implementation fit the workflows, systems, and processes of the schools. Participants stated that the most suitable time for TFT-TFS training and implementation in the schools is between June and December.

They also asserted that 45 to 60-minute monthly implementation activities, if conducted during lunchtime in the presence of all staff, would proceed smoothly and generate more meaningful discussions on TFT-TFS themes.

Individuals’ domain

One (Implementation leads) out of nine inner setting constructs emerged under this domain.¹² We defined implementation leads as those who put efforts into implementing the TFT-TFS program. We found that two sub-constructs-opportunity and capability, positively influenced on the training and implementation of the TFT-TFS program.

Implementation leads (Opportunity)

Participants viewed teachers as most suitable for TFT-TFS smartphone-based training and implementation, citing their success in government programs and smartphone access. Principals highlighted that because to heavy administrative workloads, they might not be available to serve as the TFT-TFS program implementer in their schools.

However, they would designate any teacher as ‘program in-charge’ (implementers) for smartphone-based TFT-TFS training and implementation in their schools. Principals stated that designated teachers would follow their instructions and inform them about the progress in TFT-TFS training and implementation.

Implementation leads (Capability)

This sub-construct refers to having prior knowledge and skills of getting trained and implementing other government programs as a facilitator to fulfill the role of implementation leads.

Participants perceived that exposure to previous school-related training through Android apps provided them with the skills needed to continue to get the trained for the TFT-TFS program through a smartphone-based Android app.

DISCUSSION

Findings suggest that the domains of innovation, inner setting, and individuals have strong facilitators (+) while the domains of outer setting have strong barriers (–) (Figure 2). This pattern is similar to that found in other implementation studies from the healthcare context.^14,24,25 Studies suggest that using enjoyable and effective game mechanics, such as adding points, badges, or leaderboards to an activity, and incorporating game-like challenges and feedback into a process to monitor implementation can help increase engagement, intrinsic motivation, and participation in the task or activity achieving the intended learning or behavior change outcomes.^26-29 Gamification, defined as using game design features in non-game settings, can enhance the engagement of daily repetitive work while providing motivational and cognitive advantages.³⁰ A systematic review on serious games and gamification done in 2023 found that the most common game mechanics and design elements used in serious games and gamification for health include points, badges, leaderboards, storytelling and narratives, virtual rewards, incentives, and game-based assessments, which corroborates with our formative study findings.³¹

Our findings highlight the acceptability and accessibility of Android-based apps (Innovation design) post-COVID-19 as a facilitator for the TFT-TFS app. This aligns with a 2022 study reporting increased smartphone use among adults because of COVID-19.³² Participants suggested that push notifications would enhance engagement and act as reminders to complete monthly activities on time. Research supports push notifications (texts, emails, etc.) as effective intervention prompts for increasing engagement and motivation in smartphone-based health behavior change interventions, thus improving health outcomes, and poorly designed notifications may lead to app uninstallation.^33,34 The impact of notification frequency remains unclear-Pham et al warned of negative effects, while Morrison et al found that frequent notifications increased engagement.³³ Participants also recommended minimizing app size and mobile data usage from the users' smartphones. Considering these innovation facilitators, the study team did the following to enhance engagement and implementation: (1) developed the TFT-TFS Android-based smartphone app with gamified features to enhance engagement and implementation, (2) created push notifications for each of the monthly TFT-TFS themes, (3) designed gamified features, as described above for the lowest possible Android version, and (4) ensured the TFT-TFS Android app and training related audio-visuals consume minimal space and data. Users can access videos and other features within the app without requiring them to download it (Innovation design). We also optimized TFT-TFS app for mobile data efficiency.

From the inner settings domain, the study team added tangible incentives to enhance implementation through gamified features, such as certificates for top-performing schools. Findings from the culture (Recipient-centeredness) domain showed about 30% of tobacco users in schools and communities, a close match to the global adult tobacco survey-round 2 (28.6%).³⁵ Participants reported that other schools had tobacco users but not theirs, likely because of social desirability bias, as the government is encouraging schools to implement ToFEI guidelines.²³ This under-reporting mirrors findings from a study on women of reproductive age, which showed that the odds of women under-reporting SLT use were higher in Central and Western India because of social desirability or the presence of a third person during the survey interview.³⁶ Participants perceived that existing strong communication via WhatsApp and official permissions can ensure timely implementation, which goes in line with another study, which was conducted to identify facilitators and barriers that affect the implementation of three EBIs to improve colorectal cancer. The study incorporated 16 semi-structured interviews guided by the CFIR to describe diverse stakeholders’ implementation experience found poor communication as one of the implementation barriers.²⁵ Additionally, mission alignment was another perceived facilitator, as schools already follow ToFEI guidelines and the government cleanliness campaign.^22,23

In the outer setting domain, findings highlighted teachers' limited time spent in the school because of administrative overload, affecting their primary role of teaching. Delhi schools reported similar concerns in 2019.³⁷ To address this, the study team designed the TFT-TFS Android app for training and implementing monthly activities to last for 45-60 minutes each month for six months. Local conditions also emphasized government initiatives like the 100-yard tobacco ban (ToFEI) and government cleanliness campaign as key facilitators for successful TFT-TFS implementation via Android app-based training.^22,23 Participants suggested that the TFT-TFS Android app-based training would also be effective by raising awareness of SLT and alcohol use. They noted the lack of statutory warnings in OTT web series depicting tobacco/alcohol consumption. We conducted this formative research in 2022, before India’s revised OTT rules (Sept 1, 2023) aimed at countering tobacco promotion, though compliance remains weak.³⁸ Acknowledging these factors, the study team developed audio-visual content with relevant stories and characters.

Incorporating the individuals domain ensures the TFT-TFS app-based training is engaging and effective. Under implementation leads, participants emphasized teachers' key role in activities benefiting children and communities, supporting their involvement in TFT-TFS. They also confirmed that all teachers own smartphones and can receive app-based training, boosting confidence in TFT-TFS app development. Participants saw training during school hours as a facilitator. Despite challenges, they expressed interest in TFT-TFS app-based training and implementation, aligning with studies from India, where teachers made painstaking efforts to stay committed and teach effectively in their schools despite the simultaneous allocation of additional responsibilities, either non-academic or requiring travel outside school.³⁹

The study had several strengths. First, we used the CFIR framework to develop data collection tools, analyze data, and design training and implementation strategies. This helped us assess the MP context before developing the TFT-TFS app, ensuring the incorporation of local insights. This approach helped address locally perceived facilitators and barriers to enhance implementation. Second, the use of multiple analysts in the study team to repeatedly reviewed the codes and transcripts and matched them with the CFIR domains ensured greater conceptual clarity, rigorous analysis, and appropriate interpretation. Third, we conducted the study across multiple districts in MP, covering a broad spectrum of rural, urban, and tribal cultures. This diversity strengthened the study by integrating varied contextual information and optimizing TFT-TFS Android app-based training and implementation needs. Fourth, the study employed triangulation by integrating data from FGDs, KIIs, and direct school observations. This comprehensive approach provided a holistic understanding of local contexts, reinforcing the reliability of the findings.

Despite these strengths, the study had a few limitations. Four out of 14 FGDs had fewer than eight participants, and eight of 10 FGDs had over 10 participants, which does not meet the formal FGD criterion of 8-10 participants.⁴⁰ However, this reflects the natural school setting, since some schools had only two or four appointed teachers to run the entire school. Other schools having more teachers present on the day of FGDs wanted to participate despite inviting 8-10 teachers, as they found TFT-TFS a novel program. So, we did not prohibit them from participating in the formative study.

CONCLUSION

Understanding contextual factors is crucial for successful program implementation. CFIR was invaluable in framing data collection tools, analyzing data, and designing training and implementation strategies. Applying CFIR domains revealed the inner setting as a strong facilitator, while the innovation, outer setting, and individual domains presented mixed facilitators and barriers. This emphasized the need to focus on innovation design, critical incidents, local attitudes, and policies when developing the TFT-TFS smartphone-based training app for schools.

ACKNOWLEDGMENTS

The authors would like to thank to education department of the MP State government for its support of this study. Also, to study team, field investigators in India who contributed to this study, including Mr. Arjun Hamad, Ms. Mahewash Ansari, and Mr. Bakul Sharma for their contributions. In addition, participation of the schools and school personnel from government schools in MP and MP voluntary health association.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee National Cancer Institute of the National Institutes of Health, Division of Cancer Control & Population Sciences (DCCPS), Grant Number: 1R01CA248910.

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