International Journal of Noncommunicable Diseases

ORIGINAL ARTICLE
Year
: 2022  |  Volume : 7  |  Issue : 1  |  Page : 30--35

Punjab substance abuse prevention model: Outcomes of key multistakeholder consultation in Punjab, India


JS Thakur, Nidhi Jaswal 
 Department of Community Medicine and School of Public Health, PGIMER, Chandigarh, India

Correspondence Address:
Dr. J S Thakur
Department of Community Medicine and School of Public Health, PGIMER, Chandigarh
India

Abstract

Background: Extensive work has been done in the state of Punjab regarding the treatment of substance abuse, but focus on prevention was lacking. De-addiction services are being provided in almost each and every district of Punjab. A strong prevention and control component, i.e., prevention strategy along with de-addiction services, is crucial for desired impact. An attempt was made to develop a statewide prevention strategy against substance abuse in the state of Punjab, India, on the request of the state government. Materials and Methods: The plan of the prevention model was prepared based on the situation analysis, stakeholders' workshops, and consultative meetings with various key stakeholders from the state of Punjab. Results: One in seven (~15%) people in Punjab were currently dependent on any substance, including licit and illicit. This figure, when compared in a global context was much higher than expected. Overall substance use was predominant in men and significantly more common in rural areas. The prevention strategy in Punjab named 'Punjab Substance abuse Prevention Plan (P-SAP)' will have a holistic approach focusing on health promotion and continuum of care approach (Prevention-Treatment-Rehabilitation) targeting Supply-Demand-Harm reduction Measures. It is the first of its kind of inclusive multi-sectoral model that aims to prevent substance abuse at village, block, district and state level. Implementation requires political and administrative will with participation of all political parties and key stakeholders. Life skill education should be introduced in school education and should become part of curriculum. The state should ensure the institutional framework and mechanism for their participation and adequate resources for effective implementation. Conclusion: This model should be implemented in the state and can be tried and adapted in other states of India and low- and middle-income countries.



How to cite this article:
Thakur J S, Jaswal N. Punjab substance abuse prevention model: Outcomes of key multistakeholder consultation in Punjab, India.Int J Non-Commun Dis 2022;7:30-35


How to cite this URL:
Thakur J S, Jaswal N. Punjab substance abuse prevention model: Outcomes of key multistakeholder consultation in Punjab, India. Int J Non-Commun Dis [serial online] 2022 [cited 2022 Jun 26 ];7:30-35
Available from: https://www.ijncd.org/text.asp?2022/7/1/31/342083


Full Text



 Introduction



Substance abuse is a psychosocial problem with profound public health implications. Studies have reported that the age of 16–21 is most vulnerable for drug addiction, and the frequency of drug intake increases with age.[1] The youth are especially vulnerable as they do not perceive themselves to be “in danger.” The National Survey on the extent, pattern, and trends of substance abuse in India revealed that there are about 73 million users of drugs (including alcohol) in India, of which 13 million are dependent. Every year, about 55,000 children (especially males) take up to smoking. These children generally hail from low socioeconomic strata, poor social support, broken homes, and victims of deprivation and discrimination.[2]

According to the World Drug Report (2017), 29.5 million people globally suffer from drug use disorders. Opioids were the most harmful drug type in 2015 and accounted for 70% of the negative health impact associated with drug use disorders worldwide.[3] As per the National Mental Health Survey (2015–2016), the prevalence of tobacco use disorders, alcohol use disorders, and other substance use disorders is 5.4%, 7.9%, and 2.5% in Punjab, respectively.[4]

A recent epidemiological survey on substance abuse carried out in Punjab indicates that the prevalence of lifetime and current (12 months) dependence on any substance was 15.8% (95% confidence interval [CI]: 15.1–16.4%) and 14.7% (95% CI: 14.1–15.3%), respectively. Of the specific substances, current dependence was the highest on alcohol (10.9%; 95% CI: 10.3–11.4%), followed by tobacco (8.1%; 95% CI: 7.7–8.6%). Regarding opioids, lifetime use was 1.9% (95% CI: 1.6–2.1%) and current dependence 0.8% (95% CI: 0.7–1.0%). Use and dependence on natural opioids were the highest. Overall, substance use was predominant in men and significantly more common in rural areas.[5]

The factors such as stress, poverty, experimentation, and peer pressure play an essential role in the initiation, maintenance, and therapeutic intervention of substance abuse.[2]

De-addiction services with a focus on treatment are being provided in all districts of Punjab. Three-tier pyramid model for treatment is already being implemented in Punjab, but it does not cover the prevention and control of substance abuse in the state.[6] A strong prevention and control component is critical and crucial for substance abuse prevention in the state. This paper reports the process of development and outcomes for such a statewide prevention model.

 Materials and Methods



The government of Punjab sent an invitation to one of the authors (JS Thakur) to chalk out a statewide prevention plan against substance abuse for the state of Punjab. The objective of the prevention model was prepared based on the situation analysis, stakeholders' workshops, and consultative meetings with key officials of Punjab state such as Advisor Health, Punjab; Principal Secretary, Health and Family Welfare and related departments; Special Secretary Health; consultants from Mental Health Cell, Punjab; and Central Narcotic Control Bureau, Chandigarh. The strategies and activities of the draft plan were shared by the authors in a high-level workshop of key stakeholders held on March 1, 2015, at Mohali. The revisions suggested in the meeting were incorporated. Final draft plan of the prevention plan was discussed during the state-level workshop of stakeholders comprising state officials from key stakeholder departments, civil surgeons from all districts of Punjab, heads of the departments of sociology/social work from 3 key universities, and representatives from nongovernment organization (NGO), held on April 10, 2015, at State Institute of Health and Family Welfare (SIHFW), Mohali. Based on the discussion, a draft prevention plan was prepared and circulated for further inputs, finalized, and submitted to the state government.

 Results



The article is divided into five sections: Punjab substance abuse Prevention Plan (P-SAP), strategy, key activities in the plan, key stakeholders and role of partners, and phases of P-SAP and costing of P-SAP at district and state levels.

Punjab substance abuse prevention plan

P-SAP is holistic, focusing on health promotion and a continuum of care approach (Prevention-Treatment-Rehabilitation), targeting supply and demand-harm reduction measures as a critical strategy. Supply reduction efforts generally involve attempts to disrupt the manufacturing, distribution, and supply chains of illegal drugs through international and state borders. Demand reduction refers to efforts to reduce the public desire for illicit drugs such as de-addiction services. Harm reduction (or harm minimization) is a range of public health policies designed to reduce the harmful consequences associated with various human behaviors (legal or illegal).

Key activities in the prevention plan

Following are the key activities proposed under the plan:

Supply reduction activities

Strict enforcement will be done to disrupt supply chain through international and state borders; Establishment of State Resource Center for substance abuse within the State Health Resource Center in Punjab would be ensured; fixation of percentage of budget allocation for prevention of substance abuse activities would be ensured; review of state excise policy will be done to reduce the number of alcohol shops both in urban and rural Punjab; increased value-added tax on the tobacco products will be levied; strict punishments along with fines would be imposed on the owners of alcohol shops without license; and discussion with adjoining states for partnership, especially Rajasthan, will be held.[7]

Demand reduction activities

Resource centers will be developed to build the capacity of health and non-health sector; social marketing of the campaign will be done; sensitization meetings will be held to discuss the district level, block level and village level action plan; De-addiction services in the state will be strengthened and synergy between prevention plan and complementary and supplementary role of treatment services in the district would be maintained.

Harm reduction strategies

Activities of State AIDS Control Society Punjab and related programs such as harm reduction program for injecting drug users (IDUs) would be linked. In harm reduction strategy, the following steps can be followed after encouraging IDUs to always use clean needles/syringes,

Drug substitution therapy programDrug dependence treatment programProvide vocational training or assist in getting a suitable jobProvide family counseling to promote acceptanceLong-term rehabilitation

Refer to treatment for hepatitis B virus and/or hepatitis C virus.

Key stakeholders and role of partners

Both health and nonhealth sectors such as Home (police), sports and youth affairs, education and NGOs would partner the P-SAP. The health sector would contribute in providing stewardship, building capacity, delivering services, providing technical support, monitoring and evaluation, awareness generation, and conducting research. Among nonhealth sectors, Department of Home will take care of law enforcement for interruption in supply of drugs; District Drug and Rehabilitation Society will provide support in the development of District Action Plan and its implementation by ensuring coordination among other relevant nonhealth departments; Department of Social Justice and Empowerment will be responsible for capacity building, providing resources, social marketing, and focused implementation of the campaign; Department of Education will be involved in review of curriculum, implementation of the campaign, and formation of regional resource centers (RRCs) for implementing and coordinating school- and college-level activities; Department of Sports and Youth Affairs will help in the organization of IEC/BCC activities for generating awareness at the district, village and community level. Religious/spiritual organizations will help in the advocacy of the 'Sehatmand, Nashamukat, Khushaal Punjab campaign'. The local non-governmental organizations (NGOs) will collaborate with the government institutions/organizations for the planning and organization of the awareness activities at the village level.

Phases of Punjab substance abuse prevention plan

The plan would be carried out in three phases although state can adapt to the requirements. Each phase is described as follows:

Phase 1 – Sensitization and Launch of Punjab substance abuse prevention plan

A sensitization meeting of 200–250 stakeholders from health, education, youth, and social welfare departments would be organized at SIHFW, Punjab. P-DAP will be launched initially for 1 year and would extend for 5 years and then continued.

Phase 2 – Implementation of Punjab substance abuse prevention plan

Capacity building

Two 3-day trainings of trainers would be held to build the capacity of key stakeholders. Representatives from district (faculty from the departments of sociology, psychology and social work, education, social welfare, and youth and sports) would be trained. The State Medical College or National Institute like National Institute of Nursing Education, PGIMER, Chandigarh, along with DDTC, PGI, would train one representative from each of the 150 nursing institutes. A pool of state-level master trainers would be developed for training representatives at a block/village/school/college level. The cascade model of trainings is given in [Figure 1].{Figure 1}

State Mental Health Cell/State Medical College/PGIMER, as decided by the state government, would function as a State Training and Resource Center (STRC) for Prevention and Control of substance abuse in Punjab. District-level action plan: Master Trainers from key stakeholder's departments, i.e., Social Justice, Education, Youth, and health Department, would prepare Joint District-level Action Plan for P-SAP at a block/village/school/college level within 3 months of the date of initiation to be approved by District Drug and Rehabilitation Society. The RRCs would be established in each of the 5 universities in Punjab. RRCs will provide technical support, review, and help in finalizing district-level plans in their area of jurisdiction.

Peer-based approach will be used for the life skill development of the students and youth in the schools and colleges. [Figure 2] presents the relationship of LSE in primary prevention. The teacher-in-charge of NCC/NSS wing along with one physical education and one social science teacher will be selected from each school/college and would be trained by the master trainers about prevention of substance abuse. NCC/NSS wing will select a team of 5–6 boys and girls (Friends Club, Mitran Da Tola) from each school/college and their competence would be enhanced for various adolescent health issues. These trained peer educators would in turn organize substance abuse prevention/health promotion sessions among the school and college students. At a block/village level, focus will be on provision of life skill education by trained teachers, peer educators, members of youth clubs, and development of self-help groups and capacity building of community-based organizations and PRIs.{Figure 2}

Implementation of the plan

Oversight for implementation of district-level action plan will be done by regional/district resource centers/program officers. Sub-Divisional Magistrate (SDM) with the help of BDPO/SMO in-charge of health block will jointly provide supervision and monitoring. The block-level officers and trainers would build the capacity of school teachers, college teachers and peer educators (both school and nonschool going), health inspectors, block extension educators, Lady Health Visitor, Anganwadi Worker, accredited social health activist for prevention activities, and dissemination of information about prevention of substance abuse at village level. Network of youth clubs/Nehru Yuva Kendras would be involved in providing area-specific interventions and support. [Figure 3] shows the district model for implementation of P-DAP.{Figure 3}

Phase 3 – Monitoring, Evaluation, and Research

The monitoring and evaluation of the campaign would be done by the RRC. Any state medical college/training institute in the state could function as RRC. The baseline evaluation of substance abuse situation will come from epidemiological study or assessment planned by RRCs. Knowledge level of community members for substance abuse would be done by RRCs in their respective areas with support from State Training Resource Center (STRC). Mid-line evaluation would be done periodically during 5-year period. Monitoring will be done at various levels. Quarterly meetings will be held at the district and block levels. Periodic surveys would be conducted by the RRCs/Social and Preventive Medicine Department (SPM depts.) of Medical Colleges. A tool will be prepared by RRCs in consultation with STRC for quality assurance.

Efforts will be made to encourage research in the area of substance abuse or substance abuse. Provision for Research Chair in State Universities/RRC for substance abuse problem would be made. Working group on research may be established. Earmarking of budget for research under CADA Act could also be done.

Costing of Punjab substance abuse prevention plan model at state and district level

The estimated cost of implementing this model at the state level would be INR 2.45 crores (0.35 million US $) in the 1st year and INR 2.17 crores (0.31 million US $) per subsequent years. The budget includes cost for capacity building (INR 2,50,000/-) in the 1st year, implementation and monitoring, and evaluation (INR 2,40,000/-per year). A STRC would be established at the state level. Cost for setting up STRC will be around INR 50.9 lakhs (0.072 million US $). However, this model will annually cost INR 52,216/-(US $709.47) per district to be implemented.

 Discussion



Substance abuse is a psychosocial problem followed by serious public health implications.[1] A strong prevention and control component, i.e., prevention strategy along with de-addiction services, is crucial for desired impact. There is a need of holistic model with a focus on health promotion and continuum of care approach (Prevention-Treatment-Rehabilitation) targeting supply-demand-harm reduction measures.

Various administrative steps have been taken in Punjab to reduce the supply of drugs in the state. The Special Task Force was constituted on March 31, 2017, to address the illegal drug situation. It was placed under the command of the Additional Director General of Police.[8] The Station House Officer-level teams, backed by the anti-narcotics cell units, have been formed in every district. Moreover, the concerned state agencies have been directed to coordinate their activities with central agencies, such as the Narcotics Control Bureau and the Directorate of Revenue Intelligence, to check drug smuggling into Punjab from other parts of India and abroad.[9] De-addiction services are being provided in almost each district of Punjab. A total of 31 government and 70 licensed private drug de-addiction centers are functional in various districts of Punjab. Furthermore, all eight central jails in Punjab have functional de-addiction centers with a substance abuse monitoring system and visiting psychiatrists and counselors posted in these jails. Three-tier pyramid model for treatment needs to be complemented with strong prevention and control of substance abuse in the state which is presently lacking. Evidence suggests that application of stages of change model given by Prochaska and DiClemente has been successful in substance abuse behavior modification.[10] However, due to the complexity of treatment of substance use disorder, brief interventions could be tailored to different individuals. These brief interventions comprise six elements known as FRAMES which stands for feedback, responsibility, advice, menu of alternatives, empathy, and self-efficacy.[11] Both of these models are treatment based, i.e., used for secondary and tertiary prevention of substance abuse. The authors could not encounter any model which aims at the primary prevention of substance abuse. The P-SAP model is first of its kind which aims for the primary prevention of substance abuse at village, block, district, and state levels after due consultation with stakeholders. The key activities of the model take into account all three approaches of addressing substance abuse-supply reduction, demand reduction, and harm reduction. Moreover, the approach of this model is very inclusive. Participation of key stakeholders at the state, district, block, and village levels would be ensured to plan the activities and encourage community participation. Village-level planning will be useful in capturing the sociocultural factors influencing substance abuse in the state. This prevention model may increase the knowledge and attitude and empower community members, especially youth on substance abuse, build capacity of the institutions in the district for implementation of the district-wide program, promote synergy, and strengthen the pyramid model of de-addiction services and further would lead to the reduction of substance abuse problem in Punjab.

 Conclusion



Prevention of substance abuse may be an integral part of control of substance abuse in the state. Implementation requires political and administrative will and state should ensure the mechanism for their participation with a strong monitoring and evaluation system. This model can be tried and adapted in other states of India and low- and middle-income countries.

Ethical approval statement

The study did not involve any primary data collection. We received ethical exemption from the Institute Ethics Committee, PGIMER, Chandigarh.

 Acknowledgments



We would like to acknowledge the guidance and support provided by Dr. KK Talwar, Advisor (Health), Government of Punjab, and Ms. Vini Mahajan, IAS, then Principal Secretary, Department of Health and Family Welfare, Punjab, in developing the drug prevention plan. Our acknowledgment to all the key stakeholders from the state of Punjab for their active participation in the development and review of substance abuse prevention plan.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Ahuja R. Social Problems in India. 2nd Edition. Rawat Publications. Jaipur, 1997.
2Torrens PR, Lynch BS, Bonnie RJ; Institute of Medicine (US) Committee on Preventing Nicotine Addiction in Children and Youths. Growing up Tobacco Free: Preventing Nicotine Addiction in Children and Youths. Washington (DC): National Academies Press (US); 1994. Available from: https://www.ncbi.nlm.nih.gov/books/NBK236763/doi: 10.17226/4757. [Last accessed on 2015 Dec 07].
3United Nations Office on Drugs and Crime, World Drug Report 2017 (ISBN: 978-92-1-148291-1, eISBN: 978-92-1-060623-3, United Nations publication, Sales No. E.17.XI.6). Available from https://www.unodc.org/wdr2017/field/Booklet_1_EXSUM.pdf. [Last accessed on 2019 May 05].
4Ministry of Health and Family Welfare, Government of India. Natl Inst Ment Heal Neuro Sciences; National Mental Health Survey of India, 2015-16: Prevelance, Patterns and Outcomes. Available from: http://indianmhs.nimhans.ac.in/Docs/Report2.pdf. [Last accessed on 2019 May 08].
5Avasthi A, Basu D, Subodh BN, Gupta PK, Sidhu BS, Gargi PD, et al. Epidemiology of substance use and dependence in the state of Punjab, India: Results of a household survey on a statewide representative sample. Asian J Psychiatr 2018;33:18-29.
6Basu D, Avasthi A. Strategy for the management of substance use disorders in the State of Punjab: Developing a structural model of state-level de-addiction services in the health sector (the “Punjab model”). Indian J Psychiatry 2015;57:9-20.
7Addiction Journal. Punjab Government to Introduce the Comprehensive Action Against substance abuse Act (CADA); 2021. Available from: https://www.newindianexpress.com/nation/2021/mar/31/in-a-first-punjab-govt-to-bring-in-comprehensive-action-against-drug-abuse-act-2283924.html. [Last accessed on 2021 Dec 10].
8Ravinder V. Will Make the Fight Against Drugs a People's Movement: ADGP Harpreet Sidhu; April 01, 2017. Available from: http://www.hindustantimes.com/punjab/ht-face-to-face-will-make-the-fight-against-drugs-a-people-s-movement-adgp-harpreet-sidhu-incharge-anti-drugs-special-task-force/story-qK9f50zEQCafRBxFq0JfUP.html. [Last accessed on 2018 Mar 14].
9Correspondent H. Time Ticking on Poll Promise, Punjab Govt Says 485 Drug Dealers Nabbed in 10 Days; March 29, 2017. Available from: http://www.hindustantimes.com/punjab/time-ticking-on-poll-promise-punjab-govt-says-485-drug-dealers-nabbed-in-10-days/story-MXURz648uSQQdMV5L7r9LJ.html. [Last accessed on 2018 Mar 14].
10Center for Substance Abuse and Treatment. Treatment Improvement Protocol (TIP) Series, No. 34. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. Available from: https://www.ncbi.nlm.nih.gov/books/NBK64944/%0A%0A. [Last accessed on 2015 Jun 06].
11Miller W, Sanchez V. Motivating young adults for treatment and lifestyle change. In: Howard G, editor. Issues in Alcohol Use and Misuse by Young Adults. Notre Dame IN: University of Notre Dame Press; 1993.