Hebbar Pragati B, Dsouza Vivek, Nagelhout Gera E, van Belle Sara, Srinivas Prashanth Nuggehalli, Schayck Onno C P van, Babu Giridhara R, Bhojani Upendra
Chronic Conditions and Public Policies Cluster, Institute of Public Health, 3009, II-A Main, 17th Cross, KR Road, Siddanana Layout, Banashankari Stage II, Bengaluru, Karnataka 560070, India.
Department of Health Promotion, Maastricht University, P. Debyeplein 1, 6229 HA, Maastricht P.O. Box 616, 6200 MD, The Netherlands.
Health Policy Plan. 2025 Feb 6;40(2):140-152. doi: 10.1093/heapol/czae081.
There is a growing interest in studying and unpacking the implementation of policies and programmes as it provides an opportunity to reduce the policy translation time lag taken for research findings to translate into policies and be implemented and to understand why policies may fail. Realist evaluation is a theory-driven approach that embraces complexity and helps to identify the mechanisms generating the observed policy outcomes in a given context. We aimed to study facilitators and barriers while implementing the Cigarettes and Other Tobacco Products Act 2003 (COTPA), a comprehensive national tobacco control policy, and the National Tobacco Control Programme 2008 (NTCP), using realist evaluation. We developed an initial programme theory (IPT) based on a realist literature review of tobacco control policies in low- and middle-income countries. Three diverse states-Kerala, West Bengal and Arunachal Pradesh-with varying degrees of implementation of tobacco control laws and programmes were chosen as case studies. Within the three selected states, we conducted in-depth interviews with 48 state and district-level stakeholders and undertook non-participant observations to refine the IPT. Following this, we organized two regional consultations covering stakeholders from 20 Indian states for a second iteration to further refine the programme theory. A total of 300 intervention-context-actor-mechanism-outcome configurations were developed from the interview data, which were later synthesized into state-specific narrative programme theories for Kerala, West Bengal and Arunachal Pradesh. We identified five mechanisms: collective action, felt accountability, individual motivation, fear and prioritization that were (or were not) triggered leading to diverse implementation outcomes. We identified facilitators and barriers to implementing the COTPA and the NTCP, which have important research and practical implications for furthering the implementation of these policies as well as implementation research in India. In the future, researchers could build on the refined programme theory proposed in this study to develop a middle-range theory to explain tobacco control policy implementation in India and other low- and middle-income countries.
对政策和项目的实施进行研究和剖析的兴趣日益浓厚，因为这为减少研究结果转化为政策并得以实施所需的政策翻译时间滞后提供了契机，还能帮助理解政策可能失败的原因。现实主义评价是一种理论驱动的方法，它接纳复杂性并有助于识别在特定背景下产生观察到的政策结果的机制。我们旨在运用现实主义评价研究在实施2003年《香烟及其他烟草制品法案》（COTPA，一项全面的国家烟草控制政策）和2008年《国家烟草控制项目》（NTCP）时的促进因素和障碍。我们基于对低收入和中等收入国家烟草控制政策的现实主义文献综述，制定了一个初始项目理论（IPT）。选取了三个不同的邦——喀拉拉邦、西孟加拉邦和阿鲁纳恰尔邦——作为案例研究，它们在烟草控制法律和项目的实施程度上各不相同。在这三个选定的邦内，我们对48位邦和地区层面的利益相关者进行了深入访谈，并进行了非参与式观察以完善IPT。在此之后，我们组织了两次区域协商，涵盖来自20个印度邦的利益相关者，进行第二轮迭代以进一步完善项目理论。从访谈数据中总共得出了300个干预-背景-行动者-机制-结果配置，随后将其综合成喀拉拉邦、西孟加拉邦和阿鲁纳恰尔邦各自的叙述性项目理论。我们识别出了五种机制：集体行动、责任感、个人动机、恐惧和优先级排序，这些机制（或未）被触发，导致了不同的实施结果。我们确定了实施COTPA和NTCP的促进因素和障碍，这对于推进这些政策的实施以及印度的实施研究具有重要的研究和实际意义。未来，研究人员可以基于本研究中提出的完善后的项目理论，构建一个中观理论来解释印度及其他低收入和中等收入国家的烟草控制政策实施情况。
