Process evaluation of a tobacco prevention program in Indian schools--methods, results and lessons learnt

In India, 57% of men between 15 and 54 years and 10.8% of women between 15 and 49 years use tobacco. A wide variety of tobacco gets used and the poor and the underprivileged are the dominant victims of tobacco and its adverse consequences. Project MYTRI (Mobilizing Youth for Tobacco-Related Initiatives in India) was a tobacco prevention intervention program, a cluster-randomized trial in 32 Indian schools which aimed to decrease susceptibility to tobacco use among sixth- to ninth-grade students in urban settings in India. This culture-specific intervention, which addressed both smokeless and smoked forms of tobacco, was Indian in content and communication. We qualitatively developed indicators which would help accurately measure the dose of the intervention given, received and reached. A multi-staged process evaluation was done through both subjective and objective measures. Training the teachers critically contributed toward a rigorous implementation and also correlated with the outcomes, as did a higher proportion of students participating in the classroom discussions and better peer-leader-student communication. A sizeable proportion of subjective responses were 'socially desirable', making objective assessment a preferred methodology even for 'dose received'. The peer-led health activism was successful. Teachers' manuals need to be concise.