Prevalence of tobacco use, legal awareness and control attitudes among healthcare students, professionals and staff: a multicentric study in India

Abstract

Background

Tobacco use poses a significant global health challenge, particularly within the healthcare sector. This study assessed tobacco use prevalence, legal awareness, control attitudes and the need for greater emphasis on tobacco control in healthcare curricula among professionals, students and staff in Eastern India, specifically in Bihar and Jharkhand.

Methods

In July and August 2023, an extensive online survey was conducted across 24 tertiary healthcare institutions involving medical, dental and nursing students, as well as faculty, resident physicians, nursing professionals and support staff.

Results

The study revealed that 15.9% of participants currently use tobacco, with 9.6% reporting daily use. Notably, non-users demonstrated higher awareness of tobacco-related laws compared to users. Multifactor logistic regression analysis identified several determinants of tobacco use including age, sex, marital status, occupation, family income and geographic origin. A significant finding was that less knowledge about tobacco laws correlated strongly with higher rates of tobacco use. Furthermore, regional variations were observed, with a lower prevalence of tobacco use in participants from southern states.

Conclusions

Our findings underscore the necessity of integrating comprehensive tobacco education into healthcare curricula and reinforcing awareness campaigns to effectively mitigate tobacco use within this critical sector.

Introduction

In the global battle against tobacco, healthcare professionals (HCPs), students and workers are essential change agents, guided by evidence-based practices and the World Health Organisation (WHO) Framework Convention on Tobacco Control (FCTC), which emphasizes the role of healthcare workers as tobacco-free exemplars.^1–6 Nonetheless, the significant prevalence of tobacco use among this demographic presents a notable challenge to their effectiveness.⁷ India’s implementation of the Cigarettes and Other Tobacco Products Act (COTPA) in 2004, including measures like public smoking bans and graphic warning labels, aimed to align with international standards, with subsequent amendments focusing on enhancing regulations, including online platforms.^8–10 However, there remains a lack of widespread awareness among the general population regarding COTPA’s provisions.^11–13

Despite India’s commitment as a signatory to the WHO FCTC, the existence of the tobacco control act (COTPA) and a 17% relative reduction in the tobacco prevalence between Global Adult Tobacco Survey (GATS) 1 (2009–10) and GATS 2 (2016–17), it still maintains the unfortunate distinction of having the highest number of tobacco users globally.^14,15 Considering the gravity of the situation, healthcare workers (HCWs) have the potential to play a central role in tobacco control efforts in India. As pillars of public health, their role extends beyond individual patient care to societal impact and health system delivery. The prevalence of tobacco use among healthcare students and professionals presents a multifaceted problem with profound implications for both society and the healthcare system. First, tobacco use among these individuals contradicts the principles they uphold in promoting public health, potentially undermining their credibility and effectiveness as role models.^1–3 Moreover, the adverse health effects of tobacco not only compromise their own well-being but also result in increased healthcare costs, decreased productivity and strained resources within the health system. Additionally, tobacco use among healthcare workers can perpetuate a culture of acceptance and normalization of smoking behavior, further perpetuating the tobacco epidemic. Furthermore, the lack of awareness of tobacco-related laws and inadequate implementation of tobacco control measures among HCWs hinder comprehensive tobacco control efforts.^16–18

Addressing these challenges is crucial not only for the health and well-being of healthcare workers themselves but also for the effectiveness of tobacco control initiatives and the overall health system delivery in India. Our study aimed to provide insights into the prevalence of tobacco use, awareness of tobacco-related laws, attitudes toward tobacco control and the need for greater emphasis on tobacco control in healthcare curricula. Our research specifically targeted healthcare students, professionals and staff across tertiary care facilities in the Eastern Indian states of Bihar and Jharkhand, providing a contemporary overview of this critical issue.

Methods

Study design and participants

This study was a multicentric, observational cross-sectional investigation conducted in July and August 2023. It involved a diverse cohort of participants, including healthcare students, professionals and support staff, across 24 tertiary healthcare facilities in the Eastern Indian states of Bihar and Jharkhand. Healthcare students comprised medical, dental and nursing streams. HCPs included faculty members, resident physicians (medical and dental) and nursing professionals. Support staff roles encompassed officers, laboratory technicians, attendants, cleaning staff, guards and others. The study was led by investigators from All India Institute of Medical Sciences (AIIMS) Deoghar, a newly developing medical institution of national importance in Jharkhand, dedicated to deliver top-quality healthcare and pioneering medical research and offering world-class medical education for regional and national well-being.

A total of 20 medical colleges, including AIIMS Deoghar, and 4 dental colleges actively participated in this comprehensive survey. To initiate the study, personalized invitations were sent to all medical and dental colleges in Bihar and Jharkhand, outlining the survey’s methodology and seeking expressions of interest. In Bihar, out of the 21 medical colleges approached, 11 committed to the participating in the study. Impressively, all nine medical colleges in Jharkhand fully embraced the survey, showcasing enthusiastic participation from the state’s medical institutions. Regarding dental colleges, the response rate in Bihar saw participation from 2 out of 6 colleges, while in Jharkhand, it was notably higher with 2 out of 4 colleges taking part (Supplementary Fig. 1). Upon obtaining consent from the participating healthcare institution, we proceeded to request the nomination of at least one nodal person within each institution. These nominated individuals were tasked with overseeing and coordinating the survey within their respective institutions, following a comprehensive briefing on the study’s objectives and aims.

Based on the research conducted by Naik et al.,¹⁸ assuming that ~16.9% (~17%) of individuals in the population are daily tobacco users, response rate of 50% and considering a design effect of 2, the study would necessitate a sample size of 7503 in order to estimate the expected proportion with a precision of 10% relative to the expected proportion (equivalent to a 1.7% absolute precision) and a confidence level of 95%.¹⁹ We used a self-administered, anonymous Google Form to collect responses from potential study participants, with all items and instructions provided in English followed by their Hindi translation. This approach ensured that no identifying details were requested. The study utilized a snowball sampling technique, a non-probabilistic approach, wherein nodal individuals distributed the Google Form link within their institutions, both individually and within WhatsApp groups. Additionally, mass administration of the study Google Form occurred in lecture theaters for students and in offices and canteens for staff members. In cases where the cleaning or support staff did not have a smartphone, the respective nodal person of that center arranged smartphones for them to self-administer the Google Form.

Measures

The questionnaire was first formulated through a review of existing literature^{5,6,8,9,12,13,18,20–23} and consultations with experts from the Department of Community and Family Medicine and Psychiatry at AIIMS Deoghar. Subsequently, the questionnaire was circulated among the investigators from the other participating medical and dental colleges. During a virtual conference, the investigators collectively evaluated and achieved consensus on the questionnaire’s face, content and consensual validity. Based on the feedback and suggestions gathered in this phase, further refinements were made to the questionnaire. It was then piloted with 30 participants: 10 medical students, 10 resident doctors and 10 staff members at AIIMS Deoghar, who were not involved in the final survey. In the pilot phase, the Cronbach’s alpha values for awareness (26 items), observed compliance (9 items) and perceptions of India’s tobacco control measures (10 items) were 0.904, 0.917 and 0.786, respectively. The final questionnaire covered socio-demographic information (age, sex, religion, caste, marital status, native state), socio-economic factors (occupation, yearly family income), tobacco use status (former, current, daily), awareness, observed compliance with tobacco laws and perceptions about India’s tobacco control. The awareness questionnaire showed excellent reliability (Cronbach’s alpha coefficient: 0.924), while the control measures perception questionnaire exhibited strong reliability (Cronbach’s alpha coefficient: 0.929). The observed practices questionnaire had acceptable reliability (Cronbach’s alpha coefficient: 0.728). The study also collected data on tobacco usage patterns, nicotine dependence and quitting behaviors among current and daily tobacco users, which will be discussed in a separate manuscript.

Various definitions were employed in the study. A former tobacco user encompassed individuals who had used tobacco products at any point in their life, even if it was a singular instance. A current tobacco user referred to those who had used tobacco products within the past month, starting from the completion of the Google Form, even if it was only once. A daily tobacco user indicated individuals who consumed tobacco products daily at the time of form submission, regardless of the quantity.²⁰ Regarding awareness assessment, each of the 26 awareness items was assigned a score of 1 for a correct response. The cumulative scores determined the overall awareness score. Participants achieving a score equal to or exceeding the median of 20 were classified as having more knowledge about Indian tobacco-related laws, while those scoring below were categorized as having less knowledge in this area.

Data analysis

The data collected through Google Forms was exported into a Microsoft Excel spreadsheet and subsequently subjected to analysis using JAMOVI (version 2.3.26). Qualitative variables were represented using frequency percentages, while mean values with standard deviations (SD) were employed for quantitative variables. To assess background characteristics, awareness levels, observed practices related to various tobacco control laws, and perceptions regarding the implementation of existing tobacco control measures among both current tobacco users and non-users, we employed the chi-square test of association. To compare the awareness scores between current tobacco users and non-users, we employed an independent samples t-test. Univariate logistic regression and multivariable logistic regression were conducted to pinpoint significant factors associated with current and daily tobacco use within the study population. We used the backward likelihood ratio (LR) method to select variables for the multivariable regression model, regardless of their significance in univariate logistic regression. Model fit was assessed using the Hosmer–Lemeshow test, where a P value >0.05 indicated a well-fitting model. Models with the lowest −2 log LR and non-significant Hosmer–Lemeshow tests were ultimately reported. Odds ratios (OR) accompanied by 95% confidence intervals (CI) were utilized to quantify the strength of these associations. Throughout the analysis, a statistical significance threshold of P <0.05 was maintained.

Results

The study found that the average age of participants was 25 ± 6.9 years (range: 17–65 years) (n = 7619). Approximately 23.4% had a history of tobacco use, with 15.9% currently using tobacco and 9.6% using it daily. In terms of specific groups, 13.3% (12.4–14.3%) of healthcare students (including medical, dental and nursing), 19.0% (16.8–21.4%) of HCPs (including faculty and nursing officer) and 28.8% of staff identified themselves as current tobacco users. Among the current tobacco users (n = 1209), 39.7% reported that they are not daily users, representing 6.3% of the overall sample. Additionally, 42.6% stated that they are smokers, equating to 6.8% of the overall sample. Furthermore, 12.3% mentioned that they use smokeless tobacco, comprising 2.0% of the overall sample. Lastly, 5.4% identified as dual users, those who use both smoking and smokeless tobacco, making up 0.9% of the overall sample. Overall, 7.4% (6.7–8.1%) of healthcare students, 13.9% (12.0–16.0%) of HCPs and 22.7% of staff reported daily tobacco use. When considering daily tobacco use, nursing students had the lowest prevalence at 2.8%, while staff members had the highest at 22.7%, with an overall prevalence of 9.6%. Significant associations were found between current tobacco use status and factors such as age, sex, marital status, occupation, family income and the participants’ native state (Table 1 and Fig. 1).

Awareness of tobacco-related laws in India ranged from 51.9 to 91.4%, resulting in a mean score of 18.2 ± 6.8. Non-users displayed higher awareness in 16 of 26 items (61.5%) compared to current tobacco users, with a mean score of 17.4 ± 7.3 for users and 18.4 ± 6.7 for non-users (P < 0.001). The main sources of information were the health department (83.0%), mass media (82.7%) and family members (79.9%) (Supplementary Table 1, Supplementary Table 2 and Supplementary Fig. 2).

In the multivariable logistic regression model for current tobacco users (−2 log LR: 5799.387), the independent variables accounted for 18.4% of the outcome variability, resulting in a predictive accuracy rate (PAR) of 84.1%. The Hosmer–Lemeshow test yielded a P value of 0.077, indicating a favorable model fit. In the multivariable logistic regression model for daily tobacco users (−2 log LR: 4042.089), the independent variables explained 20.3% of the outcome variability, leading to a higher PAR of 90.4%. The Hosmer–Lemeshow test produced a P value of 0.331, still indicating an acceptable model fit. Limited knowledge of Indian tobacco laws was associated with a 20% higher likelihood of current tobacco use and a 50% higher likelihood of daily tobacco use. Regional variations in tobacco use patterns were observed. Compared to Bihar, individuals residing in southern Indian states had a 50% lower likelihood of current tobacco use and an 80% lower likelihood of daily tobacco use. In contrast, residents of North-eastern states exhibited a 120% higher likelihood of current tobacco use, while those in Jharkhand had a 40% higher likelihood of daily tobacco use. Healthcare interns and students were more prone to use tobacco than others (includes healthcare students and interns from non-medical, non-dental and non-nursing streams). Furthermore, older participants, males, individuals from scheduled castes (SCs), divorced or separated individuals, and those with higher yearly family incomes had a greater likelihood of tobacco use compared to their counterparts (Table 2).

Significant differences, ranging from 0.2 to 9.3%, were observed in compliance with or breaches of tobacco-related legislation between tobacco users and non-users across 7 out of 9 items (77.7%). The largest difference was noted for tobacco product advertisements on television (9.3%), followed by advertisements promoting tobacco cessation (8.2%) and tobacco product advertisements on social networking sites (6.4%). Similarly, perceptions of the effectiveness of tobacco control measures varied significantly between tobacco users and non-users for 8 out of 10 items (80%) (Supplementary Table 3 and Table 3).

In general, 93.6% of healthcare students (comprising 93.2% of medical students, 95.8% of dental students and 94.5% of nursing students) expressed the belief that there should be an increased emphasis on tobacco control within their respective curricula. Similarly, across healthcare faculties, 90% of respondents (specifically 88.3% of medical faculty, 95.7% of dental faculty and 89.1% of nursing faculty) advocated for a greater focus on tobacco control in their respective curricula.

Discussion

Main finding of this study

In this multicentric observational cross-sectional study using the Open Data Kit, we comprehensively assessed the prevalence of tobacco use, awareness of tobacco-related laws, attitudes toward tobacco control and the need for greater emphasis on tobacco control in healthcare curricula among healthcare students, professionals and staff in Bihar and Jharkhand, India. This pioneering study was the first of its kind to document all these aspects within this population.

What is already known on this topic

Our findings from this study revealed a complex picture of tobacco use among participants. We discovered that 15.9% of the study participants were current tobacco users. While these figures do raise valid concerns, it is worth noting that they were relatively lower than the prevalence rates reported in the GATS 2 data for India (28.6%)^14,20 as well as for the individual states of Jharkhand (38.9%)²⁴ and Bihar (25.9%).²⁵ However, it is crucial to emphasize the inherent limitations of direct comparisons between our study and GATS 2. The primary factor here is the divergence in study populations, as GATS 2 encompassed the general population, while our study focused exclusively on HCPs, students and staff.

In our study, the prevalence of current tobacco use among healthcare students was 13.3%, with medical students showing the highest prevalence at 15.2%, followed by dental students at 10.1% and nursing students at 6.2%. This is notably lower than the findings of Surani et al.,²⁶ who used data from the Global Health Professions Students Survey (2005–09) in India and reported prevalence rates of 25.0% among medical students, 15.1% among dental students and 7.9% among nursing students. Now, comparing our observations with prior studies in the country aligns with some findings but also highlights regional variations. For example, Fotedar et al.²⁷ reported a 9.0% prevalence among dental students in Himachal Pradesh, which is similar to our results. In contrast, a study in Chennai by Boopathirajan et al.²⁸ found a much lower prevalence of 4.8% among medical students. On the other hand, Iyer et al.²⁹ in Mangalore reported substantially higher rates, with 32.1% among medical interns and 20.2% among dental interns. These discrepancies underscore the complex interplay of factors influencing tobacco use among students in different regions. Extending the scope to the South-east Asian region, Sreeramareddy et al.³⁰ analyzed the Global Health Professions Students Survey (2005–09), noting varying rates from 3.3% among nursing students to 12.8% among medical students for current smoking. These findings align closely with ours, indicating consistent patterns across broader regions. Further afield, studies in Saudi Arabia (25.4%)³¹ and Croatia (30.2%)³² reported even higher prevalence rates among medical and university students, respectively, suggesting cultural and systemic differences in tobacco use globally.

Among HCPs, we found a 19.0% prevalence of current tobacco use, with senior residents at 25.6% and medical faculty at 21.2%. This contrasts with a monocentric study in southern India by Mony et al.,¹⁶ which reported only a 6.9% prevalence among doctors, likely reflecting regional differences. Comparatively, a nationwide survey by Naik et al.¹⁸ showed a prevalence of 23.4%, closely mirroring our findings. International studies further illustrate these variances; for instance, a systematic review by Nilan et al.⁷ reported a 21% pooled prevalence among healthcare workers, aligning with our data. Meanwhile, studies from Bahrain (8.6%),³³ Italy (17.8%),³⁴ Pakistan (24.1%),³⁵ China (25.3%),³⁶ Cyprus (28.2%)³⁷ and Croatia (35.1%)³⁸ show a broad range of prevalence from 8.6 to 35.1%, emphasizing global disparities in tobacco use among HCPs. We observed that 28.8% of healthcare staff were current tobacco users, which is lower than the 43.4% reported by Prasad et al.¹⁷ in Haryana but significantly higher than the 2.0% noted by Mony et al.¹⁶ in southern India. These variations may reflect different workplace cultures or control measures within healthcare facilities.

Understanding the factors influencing tobacco use among healthcare students and professionals globally is crucial due to their higher tobacco use burden. Our study found that with increasing age, the likelihood of both current and daily tobacco use rises. This finding aligns with previous research conducted in India by Vankhuma et al.³⁹ and studies conducted abroad by Zong et al.³⁶ and Zinonos et al.³⁷ Furthermore, our study highlighted a significant sexual disparity, with males having 6 to 7 times higher odds of being tobacco users compared to their female counterparts. This result was consistent with the findings of a prior Indian study by Fotedar et al.²⁷ and studies conducted abroad by Alnasser et al.³¹ and Zinonos et al.³⁷ Additionally, those who were divorced or separated had 2.6 times higher odds of being current tobacco users, a trend that was in line with the observations of Zinonos et al.³⁷ This could be attributed to the potential relational stress experienced by individuals in the absence of partner support. Moreover, our study revealed that healthcare interns and students had higher odds of tobacco use compared to the ‘Other’ category (which includes healthcare students and interns from non-medical, non-dental and non-nursing streams). While Zong et al.³⁶ identified lower educational levels as a risk factor for tobacco use, our findings suggest that education alone may not be protective. Instead, factors such as stress, workload and peer influence may play a more significant role in shaping tobacco use patterns among healthcare trainees. Additionally, individuals with higher yearly family incomes were found to have higher odds of being daily tobacco users, possibly due to the increase in purchasing power for tobacco products. When considering native state, we found that residents of the state of Jharkhand and North-eastern Indian states were more likely to be tobacco users, while natives of Southern Indian states were at lower risk for tobacco use. This discrepancy could be attributed to cultural factors or limitations in the representativeness of the study sample across all Indian states and regions.

What this study adds

One of the most significant findings of our study was related to knowledge about tobacco-related legislations implemented in India. We discovered that having less knowledge in this area was associated with a higher likelihood of both current and daily tobacco use. This underscores the critical and modifiable nature of knowledge regarding these legislations as a factor influencing tobacco use. Our study found that knowledge regarding tobacco-related legislations varied between 51.9 and 91.4%, with certain aspects, such as the prohibition of selling tobacco to minors and the requirement for public places, like hotels, to have mandatory signage, being mostly unknown to the study participants. Other studies in India, such as Verma et al.¹² and Banandur et al.,²¹ have reported varying levels of awareness of tobacco-related legislations, highlighting the need for further sensitization. Our study revealed a consensus among the majority of healthcare faculty members and students in favor of enhancing the emphasis on tobacco control within their respective curricula. HCPs, students and staff play a pivotal role in raising community awareness regarding the detrimental effects of tobacco and related legislation.² Several studies have shown that HCPs who are tobacco users are less likely to effectively deliver tobacco cessation interventions among their patients.^3,18,23 Therefore, it is imperative to periodically sensitize healthcare students, professionals and staff regarding the ill effects of tobacco, India’s tobacco products act and tobacco cessation interventions. This not only aids in reducing the burden of tobacco use within the study population but also indirectly discourages their native communities and patients from using tobacco.

Limitations of this study

Like any observational study, our research has certain limitations that should be considered. First, its cross-sectional design hindered our ability to establish causality. Longitudinal studies would have provided more reliable insights into factors associated with tobacco use. Second, our data collection relied on a self-administered Google Form, which could have introduced response bias as non-tobacco users might have been more likely to participate and tobacco users could have concealed their usage. Additionally, our use of convenience sampling, specifically the snowball approach, could have introduced sampling bias by overrepresenting certain groups when respondents shared the survey link with like-minded individuals. Therefore, when applying our findings externally, it is essential to be aware of these potential biases. Third, social desirability bias, especially regarding tobacco use, may have persisted, despite our efforts to maintain anonymity. Fourth, our study was geographically limited to Bihar and Jharkhand, two Indian states, which made the findings not universally applicable to other regions with potentially different tobacco use rates, awareness levels and attitudes. Lastly, unmeasured factors like family influence and job satisfaction, which we could not assess due to feasibility constraints, could have also played a role in the complex landscape of tobacco use.

To conclude, our study illuminates the critical need for heightened focus on tobacco control within healthcare settings, in response to the substantial use of tobacco among healthcare professionals, students and staff. We found that variations in tobacco consumption are attributable to several factors, including age, sex, marital status, occupation, income and geographic location. Additionally, a notable gap in awareness regarding India’s tobacco-related legislation has been associated with increased tobacco usage rates. This underscores the pivotal role of awareness in combatting tobacco use, thereby reinforcing the imperative to weave tobacco education more thoroughly into healthcare curricula and to perpetuate awareness campaigns.

Acknowledgements

We would like to express our heartfelt gratitude to the heads of the participating healthcare institutions, without whose support this study would not have been feasible. We also extend our thanks to all the healthcare students, professionals and staff who participated in the survey.

Authors’ contributions

BB: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing—original draft, Writing—review & editing. SV: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing—original draft, Writing—review & editing. GJ: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing—original draft, Writing—review & editing. VN: Data curation, Formal analysis, Methodology, Project administration, Software, Supervision, Validation, Visualization, Writing—original draft, Writing—review & editing. SN: Data curation, Formal analysis, Methodology, Project administration, Software, Supervision, Validation, Visualization, Writing—original draft, Writing—review & editing. VV: Data curation, Formal analysis, Project administration, Validation, Visualization, Writing—original draft, Writing—review & editing. SB: Data curation, Formal analysis, Validation, Visualization, Writing—original draft, Writing—review & editing. AA: Supervision, Validation, Visualization, Writing—original draft, Writing—review & editing. BA: Data curation, Investigation, Resources, Writing—original draft, Writing—review & editing. UK: Data curation, Investigation, Resources, Writing—original draft, Writing—review & editing. NJ: Data curation, Investigation, Resources, Writing—original draft, Writing—review & editing. ADTCCBJ: Data curation, Formal analysis, Methodology, Project administration, Software, Supervision, Validation, Visualization, Writing—original draft, Writing—review & editing. All authors thoroughly reviewed and approved the final version of the manuscript for publication. Furthermore, they unanimously reached consensus on all aspects of this work.

Funding

This study was carried out as part of a tobacco control project funded by Vital Strategies (Grant Number: INDIA-30-19). It is important to clarify that the project did not earmark a specific budget for the execution and publication of this study. The funder was not involved in conducting, reporting or publishing this manuscript.

Ethics statement

The study protocol (Ref. 2022-74-EMP-02, dated 30 January 2023) received approval from the Institutional Ethical Committee (IEC) at the All India Institute of Medical Sciences (AIIMS), Deoghar, Jharkhand, India. Before enrolling participants, we obtained informed consent online from each individual involved in the study. Throughout the process of data collection, entry, analysis and reporting, we rigorously upheld the confidentiality and anonymity of all participants. Our study adhered to the principles outlined in the Declaration of Helsinki.

Data availability

The datasets used and analyzed in the present study can be obtained from the corresponding author upon a reasonable request.

AIIMS Deoghar Tobacco Control Collaborators for Bihar & Jharkhand (ADTCCBJ)

1. Sweta Suman, Department of Community Medicine, Narayan Medical College & Hospital, Sasaram, Bihar, India

2. Rahul Chandra, Department of Community Medicine, Narayan Medical College & Hospital, Sasaram, Bihar, India

3. Navin Kumar, Department of Community Medicine, Narayan Medical College & Hospital, Sasaram, Bihar, India

4. Sanjay Kumar, Department of Microbiology, Nalanda Medical College & Hospital, Patna, Bihar, India

5. Geetika Singh, Department of Community Medicine, Netaji Subhas Medical College & Hospital, Bihta, Bihar, India

6. Animesh Gupta, Department of Community Medicine, Netaji Subhas Medical College & Hospital, Bihta, Bihar, India

7. Madhupriya, Department of Community Medicine, Netaji Subhas Medical College & Hospital, Bihta, Bihar, India

8. Soni Rani, Department of Community Medicine, Katihar Medical College, Bihar, India

9. Arun Kumar Pandey, Department of Community Medicine, Katihar Medical College, Bihar, India

10. Vikash Chandra Mishra, Department of Psychiatry, Katihar Medical College, Bihar, India

11. Arpita Rai, Department of Oral Medicine and Radiology, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India

12. Amit Vasant Mahuli, Department of Public Health Dentistry, Dental Institute, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India

13. Anit Kujur, Department of Community Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India

14. Sanjay Kumar, Department of Community Medicine, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India

15. Nidhi Prasad, Department of Community Medicine, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India

16. Jarina Begum, Department of Community Medicine, Manipal Tata Medical College, Manipal Academy of Higher Education, Manipal, India

17. Swati Shikha, Department of Community Medicine, Manipal Tata Medical College, Manipal Academy of Higher Education, Manipal, India

18. Abhishek Kumar, Department of Community Medicine, Manipal Tata Medical College, Manipal Academy of Higher Education, Manipal, India

19. Deependra Kumar Rai, Department of Pulmonary Medicine, All India Institute of Medical Sciences, Patna, Bihar, India

20. Pramod Kumar, Department of Pharmacology, All India Institute of Medical Sciences, Patna, Bihar, India

21. Shibajee Debbarma, Department of Community and Family Medicine, All India Institute of Medical Sciences, Patna, Bihar, India

22. Minti Kumari, Department of Community Dentistry, Patna Dental College & Hospital, Patna, Bihar, India

23. Rachna Raj, Department of Community Dentistry, Patna Dental College & Hospital, Patna, Bihar, India

24. Anil Raj, Department of Community Dentistry, Patna Dental College & Hospital, Patna, Bihar, India

25. Randhir Kumar, Department of Periodontology, Patna Dental College & Hospital, Patna, Bihar, India

26. Sravanthi Malempati, Department of Biochemistry, Laxmi Chandravansi Medical College & Hospital, Palamu, Jharkhand, India

27. Vijay Kumar, Department of Community Medicine, Laxmi Chandravansi Medical College & Hospital, Palamu, Jharkhand, India

28. Sanjay Kumar, Department of Pharmacology, Laxmi Chandravansi Medical College & Hospital, Palamu, Jharkhand, India

29. Sri Krishna, Department of Oral Medicine and Radiology, Hazaribag College of Dental Sciences and Hospital, Hazaribag, Jharkhand, India

30. Ankur Bhargava, Department of Oral Pathology, Hazaribag College of Dental Sciences and Hospital, Hazaribag, Jharkhand, India

31. Nishad Gawali, Department of Community Dentistry, Hazaribag College of Dental Sciences and Hospital, Hazaribag, Jharkhand, India

32. Tulika Singh, Department of Community Medicine, Radha Devi Jageshwari Memorial Medical College and Hospital, Muzaffarpur, Bihar, India

33. Prachi Priya, Department of Community Medicine, Radha Devi Jageshwari Memorial Medical College and Hospital, Muzaffarpur, Bihar, India

34. Arun Kumar, Department of Community Medicine, Radha Devi Jageshwari Memorial Medical College and Hospital, Muzaffarpur, Bihar, India

35. Neha Chaudhary, Department of Community Medicine, ESIC Medical College & Hospital, Bihta, Bihar, India

36. Lovely Kumari, Department of Community Medicine, ESIC Medical College & Hospital, Bihta, Bihar, India

37. Ravi Prakash, Department of Community Medicine, ESIC Medical College & Hospital, Bihta, Bihar, India

38. BS Suma, Department of Community Dentistry, Buddha Institute of Dental Sciences & Hospital, Patna, Bihar, India

39. Nirmala Kumari, Department of Community Dentistry, Buddha Institute of Dental Sciences & Hospital, Patna, Bihar, India

40. Shailendra Kumar, Department of Biochemistry, Buddha Institute of Dental Sciences & Hospital, Patna, Bihar, India

41. Nikhil Nishant, Department of Community Medicine, Medinirai Medical College & Hospital, Palamu, Jharkhand, India

42. Qamrul Khan, Department of Community Medicine, Medinirai Medical College & Hospital, Palamu

43. Mayank Raj, Department of Community Medicine, Medinirai Medical College & Hospital, Palamu, Jharkhand, India

44. Dhananjay Kumar, Department of Community Medicine, Sheikh Bhikhari Medical College & Hospital, Hazaribagh, Jharkhand, India

45. Chandramani Kumar, Department of Community Medicine, Sheikh Bhikhari Medical College & Hospital, Hazaribagh, Jharkhand, India

46. Rakhi Kumari, Department of Otorhinolaryngology, Sheikh Bhikhari Medical College & Hospital, Hazaribagh, Jharkhand, India

47. Rishabh Kumar Rana, Department of Community Medicine, Shahid Nirmal Mahato Medical College, Dhanbad, Jharkhand, India

48. Ravi Ranjan Jha, Department of Community Medicine, Shahid Nirmal Mahato Medical College, Dhanbad, Jharkhand, India

49. UK Ojha, Department of General Medicine, Shahid Nirmal Mahato Medical College, Dhanbad, Jharkhand, India

50. Mukesh Kumar, Department of Community Medicine, Phulo Jhano Medical College and Hospital, Dumka, Jharkhand, India

51. Mrinal Ranjan Srivastava, Department of Community Medicine, Phulo Jhano Medical College and Hospital, Dumka, Jharkhand, India

52. Pragyan Das, Department of Oral Medicine and Radiology, Awadh Dental College and Hospital, Jamshedpur, Jharkhand, India

53. Prakash Ranjan, Department of Community Medicine, Darbhanga Medical College, Darbhanga, Bihar, India

54. Sukesh Kumar, Department of Community Medicine, Darbhanga Medical College, Darbhanga, Bihar, India

55. Vikrant Kumar Singh, Department of Community Medicine, Darbhanga Medical College, Darbhanga, Bihar, India

56. Kashif Shahnawaz, Department of Community Medicine, Jannayak Karpoori Thakur Medical College and Hospital, Madhepura, Bihar, India

57. Birendra Kumar, Department of General Surgery, Jannayak Karpoori Thakur Medical College and Hospital, Madhepura, Bihar, India

58. Ganesh Kumar, Department of General Surgery, Jannayak Karpoori Thakur Medical College and Hospital, Madhepura, Bihar, India

59. Naveen Kumar, Department of Community Medicine, Bhagwan Mahavir Institute of Medical Sciences, Pawapuri, Bihar, India

60. Aman Kishor, Department of Pharmacology, Bhagwan Mahavir Institute of Medical Sciences, Pawapuri, Bihar, India

61. Rajnish Kumar, Department of Biochemistry, Bhagwan Mahavir Institute of Medical Sciences, Pawapuri, Bihar, India

62. Abhay Simba, Department of Ophthalmology, Anugrah Narayan Magadh Medical College, Gaya, Bihar, India

63. Arjun Choudhary, Department of Ophthalmology, Anugrah Narayan Magadh Medical College, Gaya, Bihar, India

64. Bishnu Deo Goel, Department of Ophthalmology, Anugrah Narayan Magadh Medical College, Gaya, Bihar, India

Bijit Biswas, Assistant Professor

Saurabh Varshney, Executive Director & Chief Executive Officer

G. Jahnavi, Professor & Head

Venkata Lakshmi Narasimha, Assistant Professor

Santanu Nath, Associate Professor

Vinayagamoorthy Venugopal, Assistant Professor

Sudip Bhattacharya, Assistant Professor

Arshad Ayub, Assistant Professor

Benazir Alam, Project Co-ordinator

Ujjwal Kumar, Research Associate

Niwedita Jha, Administration cum Financial Assistant

References

Author notes