Table 3.

Intervention package: Stages of development and adaptation.

Stages	Dimension (60)	Adaptation into the package	Strategies (62)	Surface/deep structures (61)
Defining requirements	Context	• The intervention package was developed in consultation with stakeholders that included tobacco from the state, civil society organizations (CSO) functioning in the region, program managers, and health care providers who are providing services in the state's public health system and indigenous to the population served. • This step was taken in order to better understand and incorporate the socio-cultural context into the intervention package. • Multiple consultative meetings and workshops were undertaken during the process. • During the pre-test, in-depth interviews were conducted with each category of HCPs and program managers to identify potential barriers and drivers. • HCPs were oriented on culturally appropriate ways of discussing sensitive topics concerning tobacco use in the state along with patient-centric advice by tailoring advice to their current NCD and background.	Constituent-involving	Surface
Creation of intervention	Language	• The package was created, adapted, and translated into the regional language of “Punjabi”. Also, it was adapted to Hindi as well. The booklet for health care providers was developed in English.	Linguistic	Surface
	Persons	• The text was minimized and emphasis was placed on the pictorial representation of the visuals for a better understanding of poorly literate individuals. • Real-time images were used for better representation. • Short case vignettes were adapted into the disease-specific pamphlets and booklet reflecting the problem and management strategies. • The state attracts a migratory population from central India which is largely Hindi-speaking. Since HCPs working in the system are from the state itself, they are well-versed in the local language and were encouraged to use the language at the convenience of the patient (Hindi/Punjabi).	Peripheral	Surface
	Metaphors	• The material developed had culturally relevant themes and content specific to the group. Common metaphors and couplets from Punjabi literature and religious text were incorporated into the disease-specific pamphlets. • As religion is an important and strong element of the culture of Punjab and we have incorporated excerpts from religious texts into the package.	Socio-cultural	Deep
	Content	• Locally available resources to manage cravings (dried coconut, ginger, fennel seeds, visit Gurudwara (religious shrine), and withdrawal are highlighted in the content for the users which was based on the values, belief system, and important aspects of the Punjabi lifestyle. • Based on feedback from tobacco users during the pre-test and activities to be used for managing craving were incorporated.	Socio-cultural	Surface
Delivery of intervention	Concepts	• During training workshops, the concept of confidentiality and privacy were reiterated to the health care providers. • Technical terminology was adapted into local terms to match the literacy level of participants.	Evidential	Surface
	Goals	• Tobacco use is a taboo practice many users do not disclose their tobacco use status due to the fear of being an outcast (socially boycotted). Therefore, they do not seek help to quit on their own. • Hence, we intended to harness the potential of opportunistic cessation support during their routine visit for a consultation.	Socio-cultural	Deep
	Methods	• The existing health care providers within the health care system were trained to deliver cessation intervention during the regular consultation/follow-up visits of the patients to the clinic. • The acceptance of advice offered by healthcare providers among tobacco users also increases because of faith, existing trust, and the relationship that patients have with their treating HCPs. • Appropriate revisions were incorporated into the package based on the findings of the pre-test.	Constituent-involving, Evidential	Surface