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Cervical cancer is the second leading cause of new cancer cases and cancer-related deaths among women in India, with an estimated 96,922 new cases and 60,078 deaths each year.* Despite the availability of effective low-cost screening options in India, limited access to screening and treatment services, diagnosis at a later stage, and low investment in health care infrastructure all contribute to the high number of deaths (1). In 2016 the Ministry of Health and Family Welfare of India recommended cervical cancer screening using visual inspection with acetic acid every 5 years for women aged 30-65 years (per World Health Organization [WHO] guidelines) (2,3). To establish a baseline for cervical cancer screening coverage, survey data were analyzed to estimate the percentage of women aged 30-49 years who had ever been screened for cervical cancer (defined as ever having had a cervix examination). Cervical cancer screening was estimated using data from the Fourth National Family Health Survey† (NFHS-4), a nationally representative survey conducted at the district level during 2015-2016, which included 699,686 Indian women aged 15-49 years. Lifetime cervical cancer screening prevalence was low (29.8%) and varied by geographic region, ranging from 10.0% in the Northeast Region to 45.2% in the Western Region. Prevalence of screening was higher among women with higher levels of education and household wealth, those who had ever been married, and urban residents. This screening prevalence can be used as a baseline indicator for cervical cancer screening in India in accordance with the WHO Noncommunicable Diseases Global Monitoring Framework during state-based programmatic rollout and program evaluation (4).

Summary Background Malnutrition is a major contributor to disease burden in India. To inform subnational action, we aimed to assess the disease burden due to malnutrition and the trends in its indicators in every state of India in relation to Indian and global nutrition targets. Methods We analysed the disease burden attributable to child and maternal malnutrition, and the trends in the malnutrition indicators from 1990 to 2017 in every state of India using all accessible data from multiple sources, as part of Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017. The states were categorised into three groups using their Socio-demographic Index (SDI) calculated by GBD on the basis of per capita income, mean education, and fertility rate in women younger than 25 years. We projected the prevalence of malnutrition indicators for the states of India up to 2030 on the basis of the 1990–2017 trends for comparison with India National Nutrition Mission (NNM) 2022 and WHO and UNICEF 2030 targets. Findings Malnutrition was the predominant risk factor for death in children younger than 5 years of age in every state of India in 2017, accounting for 68·2% (95% UI 65·8–70·7) of the total under-5 deaths, and the leading risk factor for health loss for all ages, responsible for 17·3% (16·3–18·2) of the total disability-adjusted life years (DALYs). The malnutrition DALY rate was much higher in the low SDI than in the middle SDI and high SDI state groups. This rate varied 6·8 times between the states in 2017, and was highest in the states of Uttar Pradesh, Bihar, Assam, and Rajasthan. The prevalence of low birthweight in India in 2017 was 21·4% (20·8–21·9), child stunting 39·3% (38·7–40·1), child wasting 15·7% (15·6–15·9), child underweight 32·7% (32·3–33·1), anaemia in children 59·7% (56·2–63·8), anaemia in women 15–49 years of age 54·4% (53·7–55·2), exclusive breastfeeding 53·3% (51·5–54·9), and child overweight 11·5% (8·5–14·9). If the trends estimated up to 2017 for the indicators in the NNM 2022 continue in India, there would be 8·9% excess prevalence for low birthweight, 9·6% for stunting, 4·8% for underweight, 11·7% for anaemia in children, and 13·8% for anaemia in women relative to the 2022 targets. For the additional indicators in the WHO and UNICEF 2030 targets, the trends up to 2017 would lead to 10·4% excess prevalence for wasting, 14·5% excess prevalence for overweight, and 10·7% less exclusive breastfeeding in 2030. The prevalence of malnutrition indicators, their rates of improvement, and the gaps between projected prevalence and targets vary substantially between the states. Interpretation Malnutrition continues to be the leading risk factor for disease burden in India. It is encouraging that India has set ambitious targets to reduce malnutrition through NNM. The trends up to 2017 indicate that substantially higher rates of improvement will be needed for all malnutrition indicators in most states to achieve the Indian 2022 and the global 2030 targets. The state-specific findings in this report indicate the effort needed in each state, which will be useful in tracking and motivating further progress. Similar subnational analyses might be useful for other low-income and middle-income countries. Funding Bill & Melinda Gates Foundation; Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Background\ud To inform actions at the district level under the National Nutrition Mission (NNM), we assessed the prevalence trends of child growth failure (CGF) indicators for all districts in India and inequality between districts within the states.\ud \ud Methods\ud We assessed the trends of CGF indicators (stunting, wasting and underweight) from 2000 to 2017 across the districts of India, aggregated from 5 × 5 km grid estimates, using all accessible data from various surveys with subnational geographical information. The states were categorised into three groups using their Socio-demographic Index (SDI) levels calculated as part of the Global Burden of Disease Study based on per capita income, mean education and fertility rate in women younger than 25 years. Inequality between districts within the states was assessed using coefficient of variation (CV). We projected the prevalence of CGF indicators for the districts up to 2030 based on the trends from 2000 to 2017 to compare with the NNM 2022 targets for stunting and underweight, and the WHO/UNICEF 2030 targets for stunting and wasting. We assessed Pearson correlation coefficient between two major national surveys for district-level estimates of CGF indicators in the states.\ud \ud Findings\ud The prevalence of stunting ranged 3.8-fold from 16.4% (95% UI 15.2–17.8) to 62.8% (95% UI 61.5–64.0) among the 723 districts of India in 2017, wasting ranged 5.4-fold from 5.5% (95% UI 5.1–6.1) to 30.0% (95% UI 28.2–31.8), and underweight ranged 4.6-fold from 11.0% (95% UI 10.5–11.9) to 51.0% (95% UI 49.9–52.1). 36.1% of the districts in India had stunting prevalence 40% or more, with 67.0% districts in the low SDI states group and only 1.1% districts in the high SDI states with this level of stunting. The prevalence of stunting declined significantly from 2010 to 2017 in 98.5% of the districts with a maximum decline of 41.2% (95% UI 40.3–42.5), wasting in 61.3% with a maximum decline of 44.0% (95% UI 42.3–46.7), and underweight in 95.0% with a maximum decline of 53.9% (95% UI 52.8–55.4). The CV varied 7.4-fold for stunting, 12.2-fold for wasting, and 8.6-fold for underweight between the states in 2017; the CV increased for stunting in 28 out of 31 states, for wasting in 16 states, and for underweight in 20 states from 2000 to 2017. In order to reach the NNM 2022 targets for stunting and underweight individually, 82.6% and 98.5% of the districts in India would need a rate of improvement higher than they had up to 2017, respectively. To achieve the WHO/UNICEF 2030 target for wasting, all districts in India would need a rate of improvement higher than they had up to 2017. The correlation between the two national surveys for district-level estimates was poor, with Pearson correlation coefficient of 0.7 only in Odisha and four small north-eastern states out of the 27 states covered by these surveys.\ud \ud Interpretation\ud CGF indicators have improved in India, but there are substantial variations between the districts in their magnitude and rate of decline, and the inequality between districts has increased in a large proportion of the states. The poor correlation between the national surveys for CGF estimates highlights the need to standardise collection of anthropometric data in India. The district-level trends in this report provide a useful reference for targeting the efforts under NNM to reduce CGF across India and meet the Indian and global targets.\ud \ud Keywords\ud Child growth failureDistrict-levelGeospatial mappingInequalityNational Nutrition MissionPrevalenceStuntingTime trendsUnder-fiveUndernutritionUnderweightWastingWHO/UNICEF targets

Effective regulation of contents of tobacco products is one of the primary milestones to reduce negative health effects associated with the use of smokeless tobacco (SLT) products. As per the available sources, testing of some SLT products has been done on ad hoc basis, but there is a lack of comprehensive and periodic analysis of these products. In addition, the available results indicate huge variations among the levels of pH, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone, N-nitrosonornicotine, benzo[a]pyrene, heavy metals and nicotine within different products as well as within different brands of the same product. This review was aimed to throw light on the variations and gaps in testing of SLT products and emphasize the need for strong policy regulation for monitoring the chemical constituents of these products.

Background & objectives: Over the past decade, the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) has served as a powerful tool to initiate and advance global tobacco control efforts. However, the control strategies have mainly targeted demand-side measures. The goal of a tobacco-free world by 2040 cannot be achieved if the supply-side measures are not addressed. This analysis was undertaken to examine the tobacco control legislations of various Parties ratifying WHO FCTC with an objective to ascertain the status of prohibition of importation, sale and manufacturing of smokeless tobacco products. Methods: All 180 Parties to WHO FCTC were included for the study. A comprehensive database of all the parties to FCTC was created and tobacco control legislations and regulations of all parties were studied in detail. Results: Overall, the sale of smokeless tobacco (SLT) products was prohibited in 45 Parties. Eleven Parties prohibited manufacturing of SLT products and six Parties imposed a ban on importation of SLT products. Australia, Bhutan, Singapore and Sri Lanka banned all three. Interpretation & conclusions: Comprehensive tobacco control strategy with effective tobacco cessation programme should complement strong legal actions such as prohibition on trade in SLT products to meet the public health objective of such laws and regulations. In addition, multisectoral efforts are needed for effective implementation of such restrictions imposed by the governments.

Background: Most patients with noncommunicable diseases (NCDs) can be managed appropriately at the primary care level, using a simplified standard protocol supported by low-cost drugs. The primary care response to common NCDs is often unstructured and inadequate in low- and middle-income countries. This study assessed the feasibility of integration of NCD prevention and control within the primary health-care system of India. Methods: This study was done among 12 subcentres, 2 primary health centres (PHCs) and one subdistrict hospital in a block in north India. All 28 multipurpose health workers of these subcentres underwent 3-day training for delivering the package of NCD interventions as a part of their routine functioning. A time–motion study was conducted before and after this, to assess the workload on a sample of the workers with and without the NCD work. Screening for risk assessment was done at domiciliary level as well as at health-facility level (opportunistic screening), and the cost was estimated based on standard costing procedures. Individuals who screened positive were investigated with electrocardiography and fasting blood sugar. PHCs were strengthened with provision of essential medicines and technologies. Results: After training, 6% of the time of workers (n = 7) was spent in the NCD-related activities, and introduction of NCD activities did not impact the coverage of other major national health programmes. Loss during referral of “at-risk” subjects (37.5% from home to subcentre and 33% from subcentre to PHC) resulted in screening efficiency being lowest at domiciliary level (1.3 cases of NCDs identified per 1000 screened). In comparison to domiciliary screening (₹21 830.6; US$ 363.8 per case identified), opportunistic screening at subdistrict level (₹794.6; US$ 13.2) was 27.5 times and opportunistic screening at PHC (₹1457.5; US$ 24.3) was 15.0 times lower. There was significant utilization of NCD services provided at PHCs, including counselling. Conclusion: Opportunistic screening appears to be feasible and a cost-effective strategy for risk screening. It is possible to integrate NCD prevention and control into primary health care in India.

To assess the effectiveness of a multi-component school based intervention in improving knowledge and behavioral practices regarding diet, physical activity and tobacco use in middle schoolchildren of rural-Ballabgarh, North-India. A total of 40 middle schools were grouped into two, based on geographic proximity and randomly assigned to the intervention or control group in a cluster randomized controlled trial. The target population consisted of 2,348 children studying in 6th and 7th grades in these schools. The intervention consisted of a school component (policies), a classroom component (activities) and a family component [Information Education & Communication (IEC) material]. The main outcome measures were knowledge and behavioral changes in physical activity, diet and tobacco which were self- reported. Post-intervention, a significant number of intervention schools adopted the tobacco policy (16/19), physical activity policy (6/19) and healthy food policy (14/19) as compared to the control schools (n = 21). Knowledge about physical activity, diet and tobacco improved significantly in the intervention group as compared to the control group. Proportion of students attending Physical Training (PT) classes for five or more days in a week in the intervention group compared to the control group increased significantly (17.8 %; p

Purpose To address high breast cancer (BC) mortality globally and especially in low- and middle-income countries (LMICs), resource-stratified screening and treatment guidelines have been provided by global expert groups. How these guidelines are implemented and aligned with facility readiness in low-resource settings is less well understood. We propose to modify, apply, and evaluate a cervical cancer toolkit designed to evaluate facility readiness in LMICs as an implementation science tool for the treatment of BC. Methods We will draw upon an existing toolkit for cervical cancer, the Improving Data for Decision Making in Global Cervical Cancer Programs (IDCCP) developed by the Centers for Disease Control and Prevention, WHO, and the George W. Bush Institute. The IDCCP includes 13 domains—for example, services, staffing, infrastructure, procurement and supply chain, equipment and supplies, referral pathways, etc—by which to assess facility readiness, and information on six categories is available in India’s District Level Household and Facility Level Survey (2012 to 2013). We applied the IDCCP toolkit for cervical cancer screening in India using District Level Household and Facility Level Survey data and propose to extend this work to include BC screening evaluation per Indian government guidelines—clinical breast exam followed by ultrasound, with or without mammography, followed by biopsy as needed across the four tiers of India’s public health care system. As a test of construct validation, we will correlate facility readiness for BC screening at the district level with self-reported BC examination data at the district level using the National Family Health Survey-4 (2015 to 2016). Results Composite scores that summarize the six categories for cervical cancer yield wide variation in facility readiness across 30 states and union territories, with a trend toward higher scores for higher levels of the public health care system. Some consistencies emerge for higher-performing states, such as Maharashtra and Goa. We will conduct similar analyses for BC screening after modifying the tool kit for BC. Conclusion The modified toolkit for either BC alone or in combination with cervical cancer can be considered an implementation science tool to by which assess facility readiness of health centers in LMICs and for understanding gaps in the implementation of government guidelines. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . No COIs from the authors.

Noncommunicable diseases (NCDs) are emerging as an important public health problem in developing countries. The risk factors for NCDs are initiated during childhood and adolescence. The aim of this review was to assess the effectiveness of school-based interventions for prevention of NCD risk factors (physical inactivity, diet, and tobacco consumption), and identify processes that affect the main outcome. The retrieved studies from 2001 to 2010 were analyzed for their methodological quality (using standard guidelines), settings, intervention components, and main outcomes. The literature search identified 37 studies. The proportion of studies showing a positive result was 83% (10/12) among those that involved family, 87%(7/8) that involved both community and family, and 76% (13/17) that involved school only. Overall, 80% of the studies reported at least some evidence of a positive intervention effect. The current literature search supports the effectiveness of school-based interventions for prevention of risk factors associated with NCDs.