Summer Internship

At

IIHMR, Delhi (April 1 to May 31st, 2020)

A Report

On

“Impact of Smoking on Other Organs Than Lungs”

By

Jyoti Tanwar (PG/19/035)

Post-Graduate Diploma in Hospital and Health Management

2019-2020
ACKNOWLEDGEMENT

Working on my project at IIHMR Delhi, during the lockdown due to COVID-19 pandemic has been a
really prominent experience on the completion of this project. In the accomplishment of this project many
people have best owned upon me their blessings and the heart pledged support.

Primarily, I would like to thank almighty GOD for being able to complete this project with success. I
thank to honorable Director of the Institution for being patron on this entire project.

I thank to Dr Anandhi Ramachandran , my mentor , whose valuable guidance has been the ones that
helped me patch this project and make it full proof success , her suggestion and instructions served as the
major contributor towards the completion of this project and I extend my gratitude to the entire staff of
the institution who helped me whenever I faced any sort of trouble.

Then I would like to thank to Mr. Jagdish , for helping me with plagiarism and research article access for
this project. Words do not suffice for the gratitude I feel towards Dr Divya Aggarwal, Human Resource
Manager and Tarun Nagpal of IIHMR DELHI , who patiently introduced me to the assignment guidelines
and arranging zoom meetings as per need. I would not have been able to meet the deadlines for my work.

Nobody has been more important to me in the persuit of this project than the members of my family , my
parents, my fiancée Dr Ashish Thakur who have helped me with their valuable suggestions and guidance
that has been very helpful in various phases of the completion of this project

Last but not the least I would like to extend my gratitude towards my dear friends and the fellow mates of
Healthcare Management who helped me alot .
 DECLARATION

I Dr Jyoti Tanwar, hereby declare that this Internship Assignments entitled “Impact of Smoking On Other Organs than
Lungs “ is the outcome of my own study undertaken under the guidance of Prof/ Dr Anandhi Ramachandran, IIHMR-
New Delhi. It has not previously formed the basis for the award of any degree, diploma, or certificate of this Institute
or of any other institute or university. I have duly acknowledged all the sources used by me in the preparation of this
field internship report.

Date: 29/06/2020

Sign:

Postgraduate Diploma in Hospital and Health Management

International Institute of Health Management Research

New Delhi
 CERTIFICATE OF COMPLETION

The certificate is awarded to

Dr Jyoti Tanwar (PG/19/035)

In recognition of having successfully completed her/ his Internship in the department of health management and has
successfully completed the project on

“Impact of Smoking on Other Organs than Lungs”

Date 29/06/2020

IIHMR DELHI

She/ He has found to be a committed, sincere and diligent student who has a strong drive & zeal for learning.

We wish him/her all the best for future endeavors

Dean- Academics & Student Affairs Mentor Name & Signature

 Certificate of Approval

The following Summer Internship Project titled “IMPACT OF SMOKING ON OTHER ORGANS THAN
LUNGS” at “IIHMR DELHI” is hereby approved as a certified study in management carried out and presented in a
manner satisfactorily to warrant its acceptance as a prerequisite for the award of Post Graduate Diploma in Health
and Hospital Management for which it has been submitted. It is understood that by this approval the undersigned do
not necessarily endorse or approve any statement made, opinion expressed or conclusion drawn therein but approve the
report only for the purpose it is submitted.

Dr Anandhi Ramachandran

Associate Professor

IIHMR, Delhi
 CASE STUDY

A Report

By

Dr Jyoti Tanwar

Post Graduation Diploma in Hospital and Health Management {2019-2021}

Questions:
Case study on Healthcare Organisation through secondry data and interviews on telephone, skype, zoom etc.
a. Select any healthcare organisation that is working in the area of your choice.
b. Study the organisational structure and operational aspects of the organisation: Organogram, Leadership, Human
Resource policies and practices , communication channels and strategies, roles and responsibilities of their team,
Services and programmes, innovations and path breaking initiatives and their local and global reach.

Abbrevation:
PHFI- Public Health Foundation Of India
MOHFW- Ministry of Health and Family Welfare
IIPH- Indian Institutes of Public Health
BCC- Behavioural Change Communication
USAID- United State Agency for International Development
CSIR- Council of Scientific and Industrial Research
ICMR- Indian Council of Medical Research
 Overview
The Public Health Foundation of India (PHFI) is a non-profit public organisation
which is working towards a healthier India. A national consultation, which was hold
by Union Ministry of Health and Family Welfare in September 2004, recommended
this foundation which can quickly improve research system, public health education
and training in India. Dr. Manmohan Singh {The Prime Minister Of India} launched
this organisation in Delhi on 28 March , 2006 .
The organisation is enabled by Government of India in 2006 to increase the public
health institutions and this foundation was set up to strengthen the training, research
policy and health system for affordable health technology, relevant research, health
promotions, policy programme ,health system connected to education in the area of
Public Health. PHFI is a liberated foundation , that adopts a wide approach to public
health and also focuses on inclusive depth of public health, that bounds the preventive,
therapeutic and promotive services. To defence the health and to deal with the
determinants of health at the population level, public health has developed as a multi-
discipilinary science, so that it can improve the health of the individual in that
particular population. The main focus of the organisation is to power the multiple
determinants of health such as social, economic, behavioural and biological to evaluate
multi-sectoral involvement and positively impact on those determinants. The
organisation also also involves the study of health systems, the management practices
and the structure for the delivery of health services to all sections of the population.
In India, the rapid health changes are observed and is challenged by an agenda of
President: Prof K Shrinath Reddy eradicate the nutritional deficiencies, infectious diseases, non-communicable diseases
Prof K Shrinath Reddy and unsafe pregnencies . The prevention of diseases ,health promotion, therapeutic
health and affordable diagnostic can be ensured by the development and health that
need a solid response in public health.

The Origin Of PHFI: Due to the increasing concern for health challenges in
the country, this organisation was formed. The PHFI concept was developed over two
years and collectively evolved through consultation with multiple constituency . For
Website : http://www.phfi.org the sustained response to public health in the country, it identified that the shortage of
health professionals is a matter of concern for development in health, and it need to be
Industries : Nonprofit Organization addressed not only for the scientific purpose but also for social purpose who need it the
most.
Company size : 501-1000
Laws: 1. New public health institutes in India needs to be established , 2.
employees Research partnership on national and international levels. , Generate new strategy and
develop strong platform for research , Establishing an liberated authorial body for
Headquarters : Delhi NCR, Delhi degree in the field of public health
NCR
Objective:- Aims to bring up interdisciplinary health promotion research
Type : Nonprofit
programme, practice and anchor on advances the multi-sectoral coordination.

Founded : 2006
Vision:- The vision of the organization is to provide strength to Public Health
Specialties : Academic Institutional system capability and give knowledge for better health outcomes
Programmes in Public Health, Public achievements for all.
Health Research, Health Promotion
Mission:- Setting standards and public health workforce development . Advancement
and Commmunication, Health
Systems Support, Public Health in public health practice , research and technology.
Training Values:- Lucidity, Impact, Quality, Independence .

Founders : In the year 2006, PHFI is created by Govt. of India along with
multiple stakeholders . Initially MoHFW , the Bill & Melinda Gates Foundation
supported for the funding of the organization that represent a real ‘Partnership for
Public Purpose’ and after this the organization is doing the work collectively with
many other stakeholders such as global foundations, state governments and the private
sector .

Leadership:

Prof. K Shrinath Reddy Mr Prashant K Singh Prof D Prabhakaran

[P [Director Coordination
[Vice President-
[President,Public Health & Strategy
Foundation Of India] Development] Research & Policy]

Ms Aprajita Roy
Ms Jasmine Samuel
[Director Human
[Executive Secretary]
Resources]

Organogram:

Framework Of PHFI:

The organization is an independently governed public and private organization which

is registered under the Societies Registration Act 1860. The Foundation is governed by
a fully empowered General Body under the government structure which has
representatives from multiple constituencies – Indian and international academic and
government and private sectors and civil societies. With the confined Rules and
Regulations, the Members of the Society elected the governing body of the
organization. The Chairperson of the General Body chairs the Executive Committee.
The President of the Society is a non-voting member of the Committee and holds the
position of the Member Secretary.
 Councils & Committees:

Academic
Advisory
Council

Institutional Research
Ethics Advisory
Committee Council

Academic Advisory
Management Council at
Committee IIPH

Setting up of PHFI & units including Indian Institutes of Public

Health (IIPH) branches also as shown in fig1.2.

PHFI is systemized as :

•academics,research, training
program •heath promotion,health system support
division

•finance,HR,infrastructure & facilities

operations •IT,legal,administration,communication
divisions

•indian institute of public health

constituents •centres of research
units

Fig1.2
 Policy and Research at PHFI : The organisation
(PHFI) advances the goals of public health in priority areas with a
law to establish a well-built network of research in public health
that will also take up policy programme and research . Broad
diversity of diseases and health system component has been passed
in research project at PHFI. During the last five years the most
important factor in the organisation’s activities is research. Mainly
focused subject areas are logical learning on human resources to
examine the plan of action in the improvement of maternal and
child mortality. Till today, the researches done by the organization
has seen in above 150+ technical publishing in reports/reviews
and 20+books .In the last year, including the particular series print
by Lancet and above 150+ publications in peer-reviewed journals.

From the beginning, by promoting programme relevant research

in prioritized health areas , the organisation also worked to set up a
strong base for public health. The organization also came to know
about the scientific interest for research and attempts to prepare a
suitable environment for student ,staff and faculty members to
study in several regulation of public health and in the research
agenda at PHFI and IIPHs.. PHFI has also been doing many
projects in different areas such as in the management of controlling
the infectious and chronic diseases, maternal and child health.

Research Areas: Thematic Research Area [fig1.3] .

Mental and Health System, Affordable

Public Health Policy and Health
Behavioural Nutrition
Disorders Financing Technologies

Social Infectious Non-

Women And
Determinants Of Diseases Communicable
Child Health
Health Diseases

Fig 1.3
 The organization has set up four Excellence centres to increase understanding and reinforce the analysis, education and training in
the preference area of public health. These centres are:

SOUTH ASIA CENTRE

FOR DISABILITY RAMALINGAN-SWAMI CENTRE FOR
CENTRE FOR CHRONIC INCLUSIVE CENTRE ON EQUITY AND EXCELLENCE IN
CONDITIONS AND DEVELOPMENT AND SOCIAL DETERMINANTS ENVIORNMENT-AL
INJURIES [CCCI] RESEARCH OF HEALTH HEALTH
[SACDIR]

The organization decides to initiate CoEs in the areas with the areas mentioned above.:

Communicable Public Health

Diseases Nutrition

Health System Maternal and

and Policy Child Health

Programs

ONGOING
THROUGH INNOVATIVE PARTNERSHIPS AND
STRATEGIES , STRENGTHEN THE TOBACCO-
CONTROL EFFORTS location: ANDHRA PRADESH &
GUJARAT
DESIGN BETTER NUTRITION POLICIES AND
PROGRAMS FOR IMPROVING NEONATAL
MATERNAL AND CHILD HEALTH OUTCOMES location:
BIHAR & UTTAR
EVALUATION IN THE PREVENTION OF HIV IN
ANDHRA PRADESH
FOR ENCOURAGEMENT OF COLLABORATION WITH
SOUTH, ESTABLISH A NETWORK OF PUBLIC HEALTH
location : NEW DELHI
Communication & Advocacy: From October 2010
– June 2011, PHFI was centered on reinforcing the execution of
BCC and campaigns for which the attempt are made across
ongoing start ups , for example- checking of health status online .
Communication endeavour for Child Health, and on universal
health coverage which supports the distribution of series in India
by Lancet and the national level programmes also. Some new
start ups was also started during that period were - : Partnership
on marketing and Health Communication on global level with
ADE Center – Improving Healthy Behaviors Project ,
Human Resources advancement for Public Health in India .

Partnership : Central and State Govt , Govt of Madhya

Pradesh (MOHFW) , Foundations and Agencies ,Govt of Jharkhand
and MCH STAR (USAID Project)

Training Division: The training division at the organisation

is controlled by Dr Sandeep Bhalla,, whose main focus is on execute
several capacity building start up’s that direct to improve the skills,
knowledge and core competencies of healthcare professionals since
2010. Several initiatives has been formed and executed for the
professionals from various background in the area of health
IIPH CAMPUS
technology, chronic conditions, monitoring and evaluation of health
programs , palliative care, health program management and quality of
healthcare. All of these training programs have been choosen by
MOHFW as an revolution model of education in their National
Innovation Summit held in 2016 at Tirupati and in 2017 at Indore.

Publications: As shown in fig 1.4

 AWARDS:

The Indian Institute of Public Health Gandhinagar,, awarded as Earth

Care Award for Leadership in Urban Climate Action 2018.(fig1.5)

BMJ Award(fig1.6)

ASSOCHAM Summit-cum-Awards on SKILLING INDIA 2015-2016

Fig 1.5

RESEARCH & ETHICS:

Public Health Foundation of India has a strong research mechanism.

Under the leadership of President & Vice President of research and
ethics, the research division handles the highly scientific research,
following and social and economic standards and transparency in the
process of decision-making , user-friendly distribution of authority and
strong evaluating mechanisms which also promotes the improvements in
research quality across the organization by providing a context for the
encouragement for innovative research ideas and for the effective
transfer of knowledge.

RESEARCH ADVISORY COUNCIL & RESEARCH MANAGEMENT

COMMITTEE : It provides the strategic directions and advice on broader
research agendas.

RESEARCH MANAGEMENT COMMITTEE : This committee

functions as an enabling forum for research and also coordinates the
acquiring of research policies, processes, systems and tools to ensure
quality, delivery and compliance for investigation alliance across the
organization by giving direction on research , translation of policy and
advise on technology development activities.

INSTITUTIONAL ETHICS COMMITTEE : It reviews all research

proposals by ethical aspects and helps in forming a solid values of morals
. Ethical process are guided by recommendations made by the ICMR .
Apart from the PHFI-IEC, the IIPH-Gandhinagar, IIPH-Hyderabad,
IIPH-Bhubaneswar and IIPH-Delhi have their own ethical committees to
review the research proposals of their faculty and students.
 RESEARCH COLLABORATIONS The organization’s
researchers are collaborating with many stakeholders include all the
All India public and state governments, individual sectors. , civilian societies.
Institute of
Hygiene &
Public Health
Latest Collaborations: Researchers at PHFI had collaborated
with a large number institutions, both national and international. A MOU
has been signed by the organization with the CSIR to do research,
especially in the area of Tuberculosis.
All India
Indian Council Collaborations Institute of
of Medical
Research in India Medical
Sciences
Planning for Future: Establishing a solid network of research
of allied institutions and to increase the goals of public health preferable
area along with the partnerships on international levels. Building 5-8 new
public health institutions over the next 6 years. The organization is
composed to unite its gains after a phase of fast growth in its initial five
Indian Clinical
years.The organization is still having a staff of research of around 120+
Epidermiology including the faculty of IIHP branches. Less than 20 of them are senior
Network researchers . Present IIPH faculty need to do the latest investment to
permit analysis and forms a surface for the long-term fieid investigations.
Along with this the organization’s plan to make a research strategy that
addresses these four challenges :.

Building
Scale and
Depth

Building
Research
Platform

Connecting Attracting
Research to High Calibre
Policy Researchers

Reference:

Public Health Foundation of India (PHFI). (n.d.). Retrieved April 19, 2020, from https://phfi.org/

MoHFW | Home. (n.d.). Retrieved April 19, 2020, from https://www.mohfw.gov.in/

Devex International Development | Devex. (n.d.). Retrieved April 19, 2020, from https://www.devex.com/

WHO | World Health Organization. (n.d.). Retrieved April 19, 2020, from https://www.who.int/

SUMMARY :

The organization is functioning towards upraising a healthier India. It strengthening the training , education , technology,
advancing in research and policy making the field of Public Health by providing best facilities. The headquarter of PHFI is
located in NEW DELHI with its IIPH branches and Applied Research Centre. This foundation was established in the year 2006
as non-profit public initiatives with many stakeholders such as State & National Govt. , civil societies , Indian and international
leaders , private sectors and other foundations. The main focus of the organization is to improve health resesearch and
technology, Setting standards and forming the public health workforce and strengthening of knowledge application , policy and
practices.
 Role of the
organization in
communicable and
non-communicable
diseases prevention
TASK-2

TASK-2
Question:

a. Based on organization selected in step 1 , try to identify the area of programmes and actions related to communicable
and non-communicable diseases.
b. Study the organisational roles and responsibilities related to their area of work in the context of national health
programmes- what is their programme objective? What are th approaches and methodology adapted? What are the
specific actions undertaken? How it is implemented? What are the deliverables and outcomes
AnteNatal and Child Health
Care in Urban SLums
(ANCHUL)

1.1 OVERVIEW : The ANCHUL Project :

Arranging, Implementation and Effectiveness of ANCHUL (AnteNatal and Child Health

care in Urban sLums) intercession.

This project is a versatile way to deal with improve the inclusion, quality and effect of MNCH care in the urban slums of Delhi.
Building up a bundle of MNCH care encouraged through a urban network laborer.

The ANCHUL intercession was created by the Indian Institute of Public Health Delhi (IIPH-D), Public Health Foundation
of India (PHFI) as a team with Delhi State Health Mission (DSHM), in light of the current ASHA program of the National
Health Mission , Government of India. The venture utilized standards of usage research to address holes and improve work
execution of ASHAs. This toolbox expects to empower the clinical officials and coaches to actualize the ANCHUL model for
choosing, preparing and supervision of ASHAs just as empowering ASHAs to viably execute their everyday duties in urban poor
networks.
1.2 COLLABORATORS:

Sunil Kharpade
Monika Rana
(Ministry Of Health Vinod Paul
(Delhi State Health and (AIIMS,Delhi)
Mission)
Family Welfare)

Sunanda K Reddy
Anuraj Shankar
(CARENIDHI,Delhi
(Havard School of
Based Grass Root
Public Health,USA)
NGO)

1.3 BACKGROUND:

Maternal, Neonatal and Child Health (MNCH) is a general wellbeing

need as it speaks to the prosperity of a general public and its potential
future. India represents 21% of worldwide under-five kid deaths1 and
17% of all worldwide maternal deaths2. Continuum of care for ladies and
kids through lifecycle and at different degrees of care targets improving
limit of wellbeing laborers. The status of MNCH and care arrangement
among urban poor shows a critical difference when contrasted with non-
poor or urban normal. There exists a comparative contrast among the
different layers of urban poor. Perceiving the condition of unexpected
weakness and poor use of wellbeing administrations in urban slums. This
strategic dependent on key highlights of the prior NRHM which has been
fruitful in conveying safe administrations to moms, babies and youngsters
through a group of laborers and ASHAs (Accredited Social Health
Activist). In 2008, Delhi State Health Mission (DSHM) spearheaded
actualizing the ASHA model in the urban regions of Delhi with
adjustments to the rustic model attributable to wide contrasts in access,
accessibility and conveyance of human services between these conditions.

In India, the urban poor toll inadequately on maternal, neonatal and

youngster wellbeing (MNCH) markers in contrast with their country
partners, and face one of a kind moves identified with MNCH.. The low
institutional conveyance rates and high newborn child mortality (IMR)
among the urban poor mirrors these conditions and imbalances, which
underscores the requirement for critical strategy and program
consideration. As well as there can be so many reasons for the cause of
under –five death in India .
1.3.1 Maternal , Neonatal and Child Health Status In Urban Poor Settlements

India represents 21% (approx. 15.7 lakh)1 of worldwide under-five

youngster passings and 17% (50,000)2 of all worldwide maternal
passings with a moderate advancement in progress of MNCH status.
The MNCH care issues can be credited to both interest just as supply
side imperatives.. The key stock side components incorporate
deficient framework and supplies, feeble referral frameworks,
problematic designation of assets and absence of coordination among
different partners in this manner prompting lacking reach of
administrations among this helpless network.

1.3.2 Role of Community Health Workers (CHWs ) in Improving Continuum of Care

The wellbeing and prosperity of ladies, infant and youngsters are reliant and overseeing it in a coordinated way can prompt
improvement in their wellbeing status. The continuum of care approach is a consistent and brought together coherence of care for
ladies and youngsters through lifecycle (youthfulness, pregnancy, labor, postnatal and neonatal periods and adolescence) and
over component of care or level of care (family unit to clinic). It targets improving the limit of wellbeing laborers, fortifying
wellbeing frameworks and improving wellbeing rehearses at family unit and network level. CHWs assume a significant job in
advancing continuum of care by filling in as a connection between the network and the wellbeing framework, along these lines
expanding the entrance to wellbeing administrations.

1.4 AIM :

To create, actualize and assess the viability of a perplexing mediation bundle to improve work execution of ASHAs in urban
slums of Delhi that would prompt increment in access to institutional conveyances and improve maternal, neonatal, kid social
insurance information and practices.

1.5 OBJECTIVE :

Improve the extent of pregnent ladies in urban slums of Delhi

Improve human service practices social insurance during ante-natal and post-natal period

Improve nourishing status of youngsters under five mortality

Obtain estimation of maternal, neonatal, newborn and still births among urban poors

Acess the procedure of potential manageability of this proposed model of MNCH care
1.6 How is ANCHUL Asha is different from Government Asha?

The different segments of ANCHUL ASHA intercession recorded beneath are ventured up procedures of the current Government
ASHA program

Competitive Choice Procedure: Modified to choose persuaded and skilled up and corners
•Enhanced Preparing: Modules That are rebuilt and introduced to the ASHAs in a sorted way to
encourage
Active Observing and Supervision: A convention for strong supervision while presenting framework
of ASHAs
•Effective Usage: Introduction of smart work for everyday execution of deliberate exercises of
ASHAs

1.7 ANCHUL Intervention :

The focal point of ANCHUL mediation is same as that of Government ASHA program. ANCHUL ASHA centers around MNCH
care alongside other wellbeing special exercises. In any case, the reason for this intercession was to investigate the achievability
of improving the work execution of ASHAs by tending to issues identified with their choice, preparing and supervision just as
empowering ASHAs to adequately execute their everyday obligations which may affect MNCH care in the urban poor networks.
The different exercises performed by the ANCHUL ASHAs are in accordance with those proposed under NHM and involve
network based MNCH advancement exercises, early referral to heath care administrations and increment mindfulness for usage
of institutional consideration during pregnancy, labor, quick baby blues period, youth ailments, family arranging measures and
other general wellbeing limited time exercises for the network individuals.

A developmental research that included a situational examination, casual conversations with the partners and audit of important
records identified with ASHA program was directed. The intercession was then structured by a procedure while drawing in with a
wide scope of partners including the arrangement creators, program implementers at DSHM and Medical officials in the
wellbeing framework. ANCHUL intervention is based on existing components of ASHA program with modified processes.

Key Process of the Program

1.7.1 Selection Process

Nomination of candiates by a Selection of ASHAs after completion of

Screening of participants using an
committee using nomination training leading to a team of back up
screening test and interview
guidelines ASHAs

1.7.2 Training Process

Intense
Rebuilt Specific
enlistment
preparing preparing to
Skill based Supervisory preparing and
modules and create
preparing module need based
maintainance relational
boost
of data aptitude
trainings

1.7.3 Supervision and Monitoring:

Framework of directors with obvious set of working responsibilities and preparing., Handholding of ASHAs and certainty
building. , Supportive supervision and critical thinking . , Objective intermittent appraisal of ASHA work execution .

1.7.4 Encouraging execution of everyday exercises with work helps and viable
utilization of information:

Scheduling and leading home visits utilizing small scale plan.

Everyday information section and report age to
evaluate execution and connecting with motivating
Conducting bunch gatherings on key points. forces

ASHA message cards, flip books, stickers, banners .

Master schedule and miniaturized scale arranging
sheets for planning visits
Regular update study of family units.

Forms and organizations to screen critical markers.

SMS alarms to ASHAs before booked home visits

Data Driven Decision Making (D3M) Software:

1.8 Assessment of ANCHUL intercession :

The viability of ANCHUL mediation was assessed utilizing a semi exploratory plan in a joint effort with DSHM. Catchment
region under two Primary Urban Health Centers (PUHCs) specifically Sangam Vihar (B-square) and Lalkaun, situated in south-
east area of Delhi with no progressing ASHA program were appointed by DSHM for the examination. ASHAs under Sangam
Vihar (B-square) PUHC were presented to the ANCHUL mediation while ASHAs under the other PUHC went about as control
and were presented to standard Government ASHA program. A sum of 18 ASHAs alongside 2 bosses and 19 ASHAs were
selected, prepared, accepted and evaluated in intercession and control arm separately, with inclusion of 9774 family units in
mediation region and 8014 families in control arm region. Quantitative techniques were received at the network level with an
emphasis on pregnant, as of late conveyed ladies and moms of under 5 youngsters to survey the adequacy of the model.
1.9 Outcomes from ANCHUL project:

Selection:

Better Accountability, Better Selection, Efficiency in training,

Better skills of ASHA such as: Counselling, Interpersonal skills
and hands-on-sessions.

Supervision:

Better monitoring: Supportive supervision with the help of ASHA

Effective use of data:

Better monitoring , timely assessment, timely payment

Day to Day activities:

Allocation of space for ASHA corner at PUHC, use of enhanced

IEC material , Community group meetings

1.9 ASHAs IN URBAN SETUP :

The National Health Mission (NHM) has made amazing accomplishments in conveyance of social insurance benefits in
provincial regions through National Rural Health Mission (NRHM) as clear from decrease in newborn child death rate (IMR),
maternal death rate (MMR), all out fruitfulness rate (TFR), increment in institutional conveyances and complete
immunization3,4. The GoI propelled National Urban Health Mission (NUHM), in light of key highlights of the previous NRHM,
to handle the wellbeing related issues of the urban populace. In 2008, Delhi State Health Mission (DSHM) spearheaded executing
the ASHA model in the urban territories of Delhi with adjustments to the rustic model attributable to wide contrasts in access,
accessibility and conveyance of social insurance between these situations. In any case, explicit execution issues like absence of
an organized preparing, vagueness in the ASHA bolster structure including jobs of care staff and the ASHAs themselves and
ineffectual utilization of an exhibition observing framework for program arranging and checking have prompted imperfect
execution of the program.
2.1 Project PaTHWay: PromoTing Health and Wellbeing

India is experiencing significant social and financial changes

prompting quick increments in the predominance of chronic
sicknesses, remarkably cardiovascular ailment, malignant growth,
diabetes and COPD. The organization’s endeavors have been
planned for building proof for understanding the NCD weight,
etiology and mediations, instruction and preparing of wellbeing
laborers and wellbeing experts, limit working from the locale to state
and national levels, wellbeing correspondence and backing to
advance wellbeing looking for practices, and affecting strategy
through investigation of proof and commitment with partners and
political administration.

Directorate of Health and Family Welfare Services, Karnataka and Public Health Foundation of India (PHFI) announce
relationship for shirking and control of Non-transferable disorders (NCDs) .

2.1.1 Overview :

Project PaTHWay is a creative conduct change arbitration on

NCD counteraction and control in numerous settings including
schools, universities and working environments over all age
gatherings. It is being driven by PHFI in a joint effort with
National Institute of Mental Health and Neuro Sciences
(NIMHANS) in Bengaluru and financed by AXA as a major
aspect of Corporate Social Responsibility (CSR) activity. The
investigation is guided by a multi-disciplinary warning panel
including specialists from WHO, scholarly organizations,
common society and government delegates. The interventions
include the following components such as:

School-based intercession: To bestow wellbeing advancement and anticipation messages for the counteraction and control of
social hazard factors adding to NCDs and to embrace a model of wellbeing advancing and sans tobacco schools. Instructors and
companion pioneers are being prepared.

College based mediation: To forestall take-up and advance stopping of tobacco and liquor use among understudies and to
advance liquor and without tobacco universities. Participatory Action Research (PAR) is being utilized to draw in youth into co-
planning such intercessions and take responsibility for own wellbeing.

Worksite mediation: To advance tobacco suspension through proactive ideas of tobacco discontinuance at work environments
with center around advancing utilization of national tobacco quit line administrations offered by the Ministry of Health and
Family Welfare, Government of India.

GLOBAL ADULT TOBACCO

SURVEY

Percentage distribution of adults ,GATS2

(2016-17)
3.1 Reinforcing OF TOBACCO-CONTROL EFFORTS THROUGH INNOVATIVE
PARTNERSHIPS AND STRATEGIES (STEPS)

Topographical area: ANDHRA PRADESH and GUJARAT

The general motivation behind this examination is to diminish the

wellbeing and financial weights of tobacco use in India, by steering
staggered activities in two states expected to fill in as champions for the
scale-up and reinforcing of the National Tobacco Control Program
(NTCP).

The particular objectives include: 1) Promote wellbeing value through

decrease in wellbeing and financial weights coming about because of
tobacco use; 2) Engage, empower and enable partners to attempt far
reaching tobacco control programs; 3) Facilitate state level activity for
viable execution of the national tobacco control program.

References:

Public Health Foundation of India (PHFI). (n.d.). Retrieved April 27, 2020, from https://phfi.org/

WHO | World Health Organization. (n.d.). Retrieved April 27, 2020, from https://www.who.int/

MoHFW | Home. (n.d.). Retrieved April 27, 2020, from https://www.mohfw.gov.in/

National Tobacco Control Programme. (n.d.). Retrieved April 27, 2020, from http://ntcp.nhp.gov.in/
 SUMMER INTERNSHIP REPORT

TASK 3

Comparative analysis of healthcare

intervention
Title: Community based mobilization for immunization coverage.

Objective: To review and compare the studies that focus on network based activation for vaccination inclusion.

Methodology:

Research Design: Literature Review Based Study

Search Strategy: Databases Searched PubMed, jGoogle jScholar jand jProQuest

Keywords: Immunization, OPV, antibody

Time Period: 2010-2019

Result: Out of all the articles, 5 are selected on the bases of network based activation for vaccination inclusion.

These studies are more focused towards the major component in changing behavior of community and change in communities
vaccine acceptance which help in preventing diseases by improving immunization coverage.

The parameters selected were the objective of study, research method, country of origin and time frame of the study.

Authors Country Objective Methodology Time

jframe

Pakis jjjj
Muhammad Atif Pakistan To access the Randomised Controlled j2017
Habib 1, Sajid acceptability and impact Trial
Soofi 1, Simon on inoculation inclusion
Cousens 2 of an incorporated
methodology for
maternal and child health
immunisation battlesork

j
Jacob Vellore , India To get with the impact of Randomized Controlled j j2013
John 1, Sidhartha IPV on intestinal Trial
Giri 1, Arun S invulnerability in
Karthikeyan 1, children recently
immunised with OPV

Roland W India To get the Randomized Controlled 2015

Sutter 1, Sunil immunogenicity of Trial
Bahl 2, Jagadish M antibody plan.
Deshpande 3

Mami Taniuchi 1, Bangladesh To get the danger of Cluster Randomised 2012

Michael Sabin 2 transmission Trial
Famulare 2, after a polio
Khalequ Zaman 3, immunisation battle with
Md Jashim Uddin
 a monovalent kind 2
OPV

Hamid Moradabad, India To get to the present Randomised 2018

Jafari, Roland W insusceptibilty profle jControlled jTrial
Sutter, after routine dosage of
T Jacob trivalent OPV and
John, Vibhor various supplemental
Jain, Ashutosh portions of type 1
Agarwal monovalent OPV and
looked at the impact of
live antibody details

Discussion:

Various articles were studied to find out the network based activation for vaccination inclusion . In these 5 articles
focusing on different domains of vaccination inclusion implemented in different countries. The following conclusion
are drawn under.

1. Community engagement and Polio Immunization Campaign :

Between June 4, 2013, and May 31, 2014, 387 groups were randomized. At pattern, 28 760 youngsters more youthful than 5
years were recorded in arm A, 30 098 in arm B, and 29 126 in arm C. The mean extent of routine immunization portions got
by youngsters more youthful than two years old enough was 43% in arm A, 52% in arm B (9%, 7-11) and 54% in arm C
(11%, 9-13; by and large p<0•0001). No genuine unfavorable occasions requiring hospitalization were accounted for after
immunisation.Despite the difficulties related with the polio end-game in high-chance, clash influenced territories of
Pakistan, a system of network assembly and focused on network based wellbeing and vaccination camps during polio
inoculation crusades was fruitful in expanding antibody inclusion, including polio immunization inclusion.

2. Effect of Single Inactivated Poliovirus Vaccine dose on Intestional Immunity

Against Poliovirus in Children :
Between Aug 19, 2013, and Sept 13, 2013, 450 youngsters were enlisted and arbitrarily alloted into study gatherings. 225
youngsters got IPV and 225 no immunization. 222 youngsters in the no antibody gathering and 224 kids in the IPV bunch
had feces tests accessible for essential examination 7 days after bOPV challenge. In the IPV gathering, 12% kids shed
serotype 1 poliovirus and 8% shed serotype 3 poliovirus contrasted and 19% and 57 26% in the no immunization gathering.
The considerable lift in intestinal resistance gave by a beneficial portion of IPV given to youngsters more youthful than 5
years who had recently gotten OPV shows a possible job for this antibody in inoculation exercises to quicken destruction
and forestall flare-ups of poliomyelitis.

3. Immunogenicity of a New Routine Vaccination for Global Poliomyelitis Prevention

:Of 900 infants selected between June 13 and Aug 29, 2013, 782 (87%) finished the per-convention necessities. Among
birth and age 18 weeks, seroconversion against poliovirus type 1 in the tOPV bunch happened in 162 of 163, in 150 of 153
in the tOPV in addition to IPV gathering. Seroconversion against poliovirus type 2 happened in 157 of 163 in the tOPV
gathering, 153 of 153 in the tOPV in addition to IPV gathering. Seroconversion against poliovirus type 3 was accomplished
in 147 of 163 in the tOPV gathering, 152 of 153 in the tOPV in addition to IPV gathering. Predominance was accomplished
 for immunization regimens including IPV against poliovirus type 3 contrasted and those excluding IPV (tOPV in addition to
IPV versus tOPV alone, p=0•0008; and bOPV in addition to IPV versus bOPV alone, p=0•0153). 12 genuine unfriendly
occasions happened (six in the tOPV gathering, one in the tOPV in addition to IPV gathering, three in the bOPV gathering,
zero in the bOPV in addition to IPV gathering, and two in the bOPV in addition to 2IPV gathering), none of which was
credited to the preliminary mediation.: The new immunization plan improves immunogenicity against polioviruses,
particularly against poliovirus type 3.

4. Community Transmission of Type 2Poliovirus after cessation of Trivalent OPV :

Between April 30, 2015, and Jan 14, 2016, people from 67 towns were enlisted to the investigation. 22 towns (300 newborn
children) were haphazardly doled out tOPV, 23 towns (310 babies) were allotted bOPV and one portion of IPV, and 22
towns (329 newborn children) were doled out bOPV and two dosages of IPV. Fecal shedding of Sabin 2 in babies who
didn't get the mOPV2 challenge didn't vary between youngsters inoculated with bOPV and a couple of dosages of IPV and
the individuals who got tOPV However, fecal shedding of Sabin 2 in family contacts was expanded altogether with bOPV
and a couple of portions of IPV contrasted and tOPV (17 of 751 [2%] versus three of 353 [1%]. Dynamical displaying of
inside family unit occurrence indicated that resistance in family unit contacts constrained transmission.In this examination,
mimicking 1 year of tOPV end, Sabin 2 transmission was higher in family unit contacts of mOPV2 beneficiaries in towns
accepting bOPV and it is possible that a couple of dosages of IPV, however transmission was not expanded in the network
in general as appeared by the non-noteworthy contrast in frequency among newborn children. Dynamical displaying
demonstrates that transmission hazard will be higher with additional time since discontinuance.

5. Immunogenicity of Supplemental doses of Poliovirus Vaccine for children aged 6-

9 months :
1002 kids enlisted, 869 (87%) finished examination systems (ie, blood test accessible at day 0 and day 28). At pattern, 862
(99%), 625 (72%), and 418 (48%) had perceivable antibodies to poliovirus types 1, 2, and 3, separately. In kids who were
type-1 seropositive, an expansion of multiple occasions in immune response titre was recognized 28 days after they were
given standard-strength mOPV1 (38%), higher-power mOPV1 (29%) , intradermal IPV (56%) , GlaxoSmithKline
intramuscular IPV (86%), and Panacea intramuscular IPV (85%). In the individuals who were type-2 seronegative, 100% of
seroconverted after GlaxoSmithKline intramuscular IPV, and 59% of after intradermal IPV . 90% of newborn children who
were type-3 seronegative seroconverted after intramuscular IPV, and 36% of after intradermal IPV . Supplemental mOPV1
brought about practically complete seroprevalence against poliovirus type 1, which is reliable with late nonappearance of
poliomyelitis cases; though seroprevalence against types 2 and 3 was normal for routine immunization chronicles. The
immunogenicity of IPV created in India (Panacea) was like that of a universally made IPV (GSK). Intradermal IPV was less
immunogenic.

Therefore all these studies point towards th successful increasing of vaccine coverage in India and also shows a
potential role for this vaccine in immunization activities to accelerate eradication and prvent the outbreak of
poliomyelitis. They also shows the improvement of immunogenicity against poliovirus especially poliovirus
type 3.

References

Government of Pakistan National Emergency Action Plan for Polio eradication 2015–2016. (n.d.). Retrieved June

30, 2020, from http://polioeradication.org/Portals/0/Document/InfectedCountries/Pakistan/2015-

16_NEAP_Pakistan.pdf

Deshpande JM, Nadkarni SS, Siddiqui ZA. Detection of MEF-1 laboratory reference strain of poliovirus type 2 in children with

poliomyelitis in India in 2002 & 2003. Indian J Med Res. 2003;118:217–223. - PubMed
Summer
Internship
report
Task 4
1.1 Title: Impact Of Smoking on Other Organs than Lungs.

1.2 Abstract: Cigarette smoking—an essential mutable hazard component for organ framework ailments and disease—
stays predominant in the United States and internationally. In this writing audit, I intend to sum up the study of disease
transmission of cigarette smoking and tobacco use and wellbeing outcome of cigarette smoking.

1.2 Objective: To find the impact of smoking on the different organs of the body than lungs in India and what kind of serious
diseases and complication can occur if a person is continued to smoke for longer time.

1.3 Introduction :

Tobacco can be portrayed as a conduct procedure that evokes mental and

physiologic addictive state of mind among clients. Nicotine, the dynamic
fixing in tobacco, is profoundly compelling, bringing about continuous use
of tobacco. Burnable tobacco items include: cigarettes, stogies, little stogies,
hookah and funnels. Non-cigarette tobacco items incorporate E-cigarettes
details created for biting, plunging . Tobacco smoke is a toxic blend of in
excess of 7,000 synthetics. The manufactured blends show up at a person's
lung quickly every time the individual takes in. The blood by then passes on
the toxicants to every organ in the body Exposure to tobacco smoke rapidly
harms veins all through the body and makes blood bound to cluster. The
manufactured blend in tobacco causes the delicate layer of the lungs and can
cause perpetual injury which lessens the volume of the lungs to trade air
effectively. Chemicals in tobacco smoke cause aggravation and cell harm.
The body makes white platelets to react to wounds, contaminations, and
malignant growths. White platelet counts will all in all stay high while an
individual continues smoking, as the body is constantly endeavoring to fight
against the mischief being realized by smoking.

As per the 2013–2014 National Adult Tobacco Survey , the US' national pervasiveness for tobacco item utilize was approx 21% in
grown-ups matured ≥18 years. Circulation of tobacco item use include: 17.3% for cigarettes, 1.84% for stogies , 0.4% for pipes,
0.7% for hookah, 3.32% for E-cigarettes.. These less famous techniques for tobacco use, while still unfortunate, hypothetically
were related with less malignant growths and tobacco related passings. Presently, its one of a kind structure and availability,
cigarette smoking has become the decision of tobacco use among numerous adolescent and grown-ups comprehensively.
Cigarettes are intended to permit profound inward breath of smoke into the lungs, conveying elevated levels of nicotine to the
cerebrum inside 10–20 s of inward breath. The quick ascent in nicotine levels makes cigarette smoking the most strengthening and
reliance delivering type by the use of tobacco . The epidemiologic impact and troublesome prosperity effects of cigarette smoking
are basic.

1.4 Composition:
1.5 Epidermiology Of Tobacco Related Diseases:

As a feature of the GBD Study did by the Harvard University School of Public Health in 1997 (4), it was anticipated horribleness
from tobacco use will increment by practically triple universal in next 25 years. Malignant growth, cardiovascular diseases and
constant obstructive aspiratory sickness keep on being the fundamental medical issues related with cigarette smoking. A broad
database has collected, which has reliably reported a connection among smoking and these particular sicknesses. The quality of
the affiliation is additionally shown by estimating the RR and the nearness of a portion reaction relationship (ie, direct connection
between the power of presentation to tobacco smoke and the danger of infection). As indicated by a 2004 Centers for Disease
Control and Prevention report, around 2600 individuals kick the bucket of cardiovascular sickness in the United States each day,
which converts into one demise each 33 s. Moreover, the probability of biting the dust from coronary illness increments fourfold
because of smoking.

1.6 Methodology:

This is a narrative report based on literature review. Several inclusion and exclusion criteria have been selected for this study
.Research paper and articles based on impact of smoking on the organs of the body expect for lungs are included in this
study(2012-2019)

Search for research article: Google Scholer, Pubmed, Medline

Keywords: Tobacco, Nicotine, Premalignant lesion, Diabetes, Secondhand smoke

Based on inclusion and exclusion criteria: 15 articles have been slected

.

Narrative review of articles: 10

 Cigarette smoking influences the human body in horde ways, affecting the improvement of ceaseless infections and malignant
growths. The prosperity impacts are found in smokers, yet also individuals introduced to utilized smoke. The effect of cigarette
smoking on prosperity depends upon the length of smoking over years and the introduction to cigarette (tobacco) smoke. The
framework by which cigarette (tobacco) smoke causes threatening prosperity results incorporates different complex advances
coming about due to the introduction to free radicals from the pieces of tobacco smoke, inciting extended oxidative weight,
disturbance, and DNA hurt. The manufactured toxic substances in tobacco smoke are moved from the lungs to the dissemination
framework, where it is moved to pretty much all parts of the human body.

Effect Of Tobacco Smoking

CARDIOVASCULAR RESPIRATORY CANCERS REPRODUCTIVE OTHERS
AA COPD Laryngeal Fetal Death Cataract
CHD Asthma Esophageal Still births Periodontitis
Stroke Pneumonia Cervical Delay Conceptions Low bone density
PVD Leukemia Hip Fracture
Pancreatic Fringe Neuropathy
1.7 Results:

1.7.1 Cancers:

Smoking is at present the biggest reason for malignancy, representing around 30% of disease related passing. Cancer-causing
agents stuck tobacco smoke tough situation to human DNA, bringing about DNA harm and quality changes.. These genetic
changes lead to uncontrolled cell advancement and curb normal segments that control cell improvement and spread, achieving
dangerous development. A causal relationship has been set up between cigarette smoking and lung sickness, the principle
wellspring of threat. There is also a causal association between cigarette smoking and tumors of the head, neck, liver, bladder,
cervix, throat, colon, and rectum. The confirmation is missing to assume that there is a causal association among smoking and
malignancies of the prostate

Cancer Statistics 2019 (INDIA)

1.7.2 Cardiovascular Diseases:

There is a causal connection between cigarette smoking and

cardiovascular occasions. Significant systems hidden smoking-actuated
cardiovascular infection incorporate endothelial brokenness,
prothrombotic impacts, aggravation, modified lipid digestion, expanded
interest for myocardial oxygen and blood, diminished flexibly of
myocardial blood and oxygen, and insulin obstruction. Cigarette
smoking and presentation to recycled smoke are significant reasons for
coronary illness, stroke, aortic aneurysm, and fringe blood vessel
infection. Cigarette smoking and used smoking are additionally a
significant reason for death due to CVD.
 Cardiac Arrest and Stroke Statistics 2019 (INDIA)

1.7.3 Reproductive Effect:

Maternal cigarette (tobacco) smoking causes a few conceptive

anomalies. Carbon monoxide in tobacco smoke ties to hemoglobin,
denying the hatchling of oxygen, eventually bringing about low birth
weight. Different poisons in tobacco smoke including nicotine,
cadmium, lead, mercury, and polycyclic fragrant hydrocarbons, have
been found to cause abrupt baby demise disorder, untimely births,
and diminished richness in ladies. Later proof demonstrates a causal
connection between maternal cigarette smoking and orofacial clefts
and ectopic pregnancies. A causal connection among smoking and
erectile brokenness in men has additionally been built up.

1.7.4 Additional Effects:

Smoking weakens resistant capacity, bringing about an expanded danger of pneumonic diseases and rheumatoid joint pain. It
likewise influences the GI tract, expanding the danger of peptic ulcer ailment. There is additionally expanded danger of hip
cracks and low bone mineral thickness in postmenopausal ladies who smoke. Furthermore, smokers with diabetes have a higher
danger of creating confusions, including nephropathy, visual impairment, fringe neuropathy, and removals . Ongoing proof
demonstrates that the danger of creating type 2 diabetes is 30–40% higher in smokers that nonsmokers . Inactive (second-hand)
smoking has additionally been connected with negative wellbeing outcomes, for example, low-birth rate in posterity of moms
presented to recycled smoke, abrupt baby passing disorder, and type 2 diabetes mellitus.
Secondhand Smoke : The unfavorable impacts of tobacco smoke on people’s wellbeing are generally perceived. This
is the fundamental etiological specialist in incessant obstructive aspiratory ailment and lung disease, and is a known human
cancer-causing agent. While the dangers to people’s wellbeing from dynamic smoking are acknowledged, proof supporting the
danger of automatic introduction to natural tobacco smoke (ETS) has aggregated lately. It is the primary wellspring of toxicant
introduction by inward breath in nonsmokers. Passive smoking is moreover associated with growing atherosclerosis in
individuals 15 to 65 years of age. Adolescents introduced to ETS are at higher peril of making cardiovascular messes

Skin: Poor blood flow because of constant vascular affront prompts impeded oxygen conveyance to the skin, making enduring
harm collagen and epithelial tissue. This marvel likewise adds to poor injury recuperating, making elective medical procedures
unsafe and crisis medical procedures risky .

Mouth: Smoking can add to terrible breath, mouth and jaw malignant growth, intermittent pharyngitis, and a diminished
feeling of taste and smell, just as recolored, yellowed teeth and plaque. Smoking lessens the progression of salivation, which,
since spit purges the covering of the mouth and teeth and shields the teeth from rot, advances contamination.

Hands and feet: Poor course leaves hands and feet

constantly inadequately perfused and cold. Strolling can get
difficult because of fringe vascular illness actuated by smoking,
which can even prompt inevitable removal. The veins in the
fingers that hold cigarettes can likewise turn out to be so
seriously hindered that gangrene can set in and lead to removal,
driving difficult smokers to change to the next hand.

After reviewing the literature it has been seen that ,smoking if one the leading cause of 15% of all deaths globally, so Ecs also
can't be viewed as protected,. Smoking raise blood pressure and heart rate and damage the lining of arteries, Smoking has been
also associated with oral conditions including premalignant lesions and oral cancers. Smokers are at a significantly increased risk
for chronic kidney disease ,tobacco use is a significant factor in miscarriages among pregnant smoker. Cigarette smoking is quite
harmful to the brain , smokers are 50% more likely to have strokes. Also causes visual impairment, nephropathy ,damage to
collagen and epithelial tissue.
1.8 Discussion:

Tobacco abuse is a major public health problem and includes secondhand smoke exposure. Continued efforts to control and
eliminate this abuse are a medical necessity. Quitting smoking provides enormous health benefits, Symptoms of asthma decrease,
pre cancer tissue may return to normal, Stopping smoking reduces the future risk of tobacco-related diseases, slows the
progression of existing tobacco-related disease, and improves life expectancy by an average of 10 years . In spite of the fact that
its pervasiveness has declined as of late, cigarette smoking remains the most well-known technique for tobacco use. The
unfriendly wellbeing impacts related with cigarette smoking are various; along these lines, ceaseless endeavors to lessen the
predominance of smoking are basic. Latest patterns on smoking feature the significance of smoking anticipation and smoking end
activities that target youngsters . Advancement of smoking discontinuance can be a solid general wellbeing approach for
decreasing non-smokers' ecological presentation to natural tobacco smoke. Rewarding tobacco reliance ought to incorporate both
social and pharmacologic mediations.

1.9 Future Perspectives :

In a perfect world, investigations of this sort will reconsider the commonness of smoking and tobacco utilize and decide the
specific idea of tobacco-related illness occurrence, the job of contributory factors, for example, dietary propensities, introduction
to different substances and the hereditary arrangement of subpopulations most in danger. Different biochemical and atomic
examines should be applied to screen nonsmoker and smoker populaces for an assortment of wellbeing dangers. Investigation of
the outcomes from such examinations will help recognize the principle communicating factors for different wellbeing dangers
and characterize connections among different epidemiological parameters . Exploration tries in the district of smoking and
prosperity would benefit by focusing on examinations of the in vivo effects of took in whole tobacco smoke in animal models of
known unequivocal genetic piece. Assurance of the genetic creation would in like manner require a comprehensive idea of the
information available from human nuclear epidemiological examinations. There are different characteristics that evidently sway
the improvement of smoke-related ailments. In this remarkable circumstance, various relevant transgenic and take out animals
that can be enough used for the examination of tobacco-related diseases are by and by opening up.
1.10 References:

WHO | World Health Organization. (n.d.). Retrieved May 25, 2020, from https://www.who.int/

National Center for Biotechnology Information.(n.d) Retrieved May 25, 2020, from https://www.ncbi.nlm.nih.gov/

American Cancer Society | Information and Resources about for Cancer: Breast, Colon, Lung, Prostate, Skin. (n.d.). Retrieved

June 8, 2020, from https://www.cancer.org/

ScienceDirect.com | Science, health and medical journals, full text articles and books. (n.d.). Retrieved June 8, 2020, from

https://www.sciencedirect.com/

Cheryl A. Oncken, William B. White, Judith L. Cooney, Jeffrey R. Van Kirk, Jasjit S. Ahluwalia, Sharon Giacco American
Journal of Hypertension(n.d) Retreived on 30,June,2020 https://doi.org/10.1016/S0895-7061(01)02147-1

Department of Health and Human Services, Public Health Service, Office of the Surgeon General (US) How tobacco smoke

causes disease: the biology and behavioral basis for smoking-attributable disease: a report of the Surgeon

General. Rockville (MD): HHS, PHS, OSG; 2010. Dec, [cited 2010 Dec 27](n.d) Retrieved June ,8,2020,

from http://www.surgeongeneral.gov/library/tobaccosmoke/index.html.