Fluorosis is a chronic metabolic bone and tooth disease caused by prolonged ingestion of excess fluoride, mainly through drinking water. It is one of the most widespread non-communicable environmental health disorders in India. Fluoride in small amounts is beneficial for dental health; however, chronic exposure beyond recommended limits leads to dental fluorosis, skeletal fluorosis, and non-skeletal manifestations involving muscles, joints, gastrointestinal tract, and nervous system. The World Health Organization recommends a fluoride concentration of 1.5 mg/L as the upper permissible limit in drinking water. In many parts of India, naturally occurring fluoride in groundwater exceeds this limit, creating a major public health challenge. India is among the countries most affected by endemic fluorosis. Several states including Rajasthan, Gujarat, Andhra Pradesh, Telangana, Chhattisgarh, Karnataka, and Uttar Pradesh have reported high fluoride levels in groundwater sources. Rural populations relying on borewells and untreated groundwater are particularly vulnerable. Children are at higher risk of dental fluorosis during tooth development, while adults exposed over longer durations may develop skeletal fluorosis characterized by pain, stiffness, restricted joint movement, osteosclerosis, and disability. Recognizing the burden of disease, the Government of India initiated the National Programme for Prevention and Control of Fluorosis (NPPCF). The programme focuses on surveillance, estimation of disease burden, laboratory support, diagnosis, management, capacity building, health education, and provision of safe drinking water through intersectoral coordination. District-level implementation forms the backbone of programme success, as local health systems are responsible for screening, referral, reporting, awareness generation, and coordination with water supply agencies. Despite the programme’s importance, many districts face operational constraints such as shortage of manpower, poor laboratory infrastructure, inadequate training, weak reporting systems, and low public awareness. Periodic programme evaluation is necessary to identify implementation gaps and improve service delivery. Chhattisgarh has several tribal and rural districts where dependence on groundwater sources increases vulnerability to fluorosis. Kanker district has reported fluoride-related concerns, yet limited scientific evidence is available regarding the status of NPPCF implementation. The present study was undertaken to evaluate the implementation status of NPPCF in Kanker district, Chhattisgarh. It also aimed to assess the functioning of major programme components and identify barriers affecting effective delivery of services. Findings from this study may support policymakers and programme managers in strengthening fluorosis control strategies in similar resource-constrained settings.

Study Design A mixed-methods cross-sectional evaluative study was conducted. Study Area The study was carried out in Kanker district, Chhattisgarh, India. Study Duration The study was conducted over one year after obtaining institutional and administrative approval. Study Population The study included: 1. District and block programme officials 2. Healthcare workers involved in NPPCF 3. Records of screened beneficiaries 4. Health facilities implementing NPPCF services Sampling Technique Purposive sampling was used for selecting programme personnel and facilities involved in NPPCF implementation. Data Collection Tools Quantitative Component A predesigned structured checklist was used to assess: • Availability of human resources • Training status • Diagnostic facilities • Availability of logistics and consumables • IEC activities • Record keeping and reporting • Referral mechanisms • Monitoring and supervision • Intersectoral coordination Qualitative Component Key informant interviews were conducted with district officials, medical officers, and field workers to identify operational barriers and facilitators. Outcome Measures Implementation scores were calculated for each programme domain and converted into percentages. Performance categories were interpreted as: • 80% = Good • 60–80% = Moderate • <60% = Poor Statistical Analysis Data were entered in Microsoft Excel and analyzed using descriptive statistics such as frequency, percentage, mean, and proportions. Qualitative responses were analyzed thematically. Ethical Consideration Institutional Ethics Committee approval and administrative permissions were obtained. Confidentiality of participants was maintained.

A comprehensive evaluation of the National Programme for Prevention and Control of Fluorosis (NPPCF) in Kanker district was undertaken across key implementation domains. The findings revealed moderate overall programme performance, with marked variability across different operational components. Diagnostic services demonstrated satisfactory functioning, whereas human resources, IEC activities, and intersectoral coordination remained suboptimal. 1. Overall Implementation Performance The cumulative implementation score across all assessed domains was 62.5%, indicating moderate implementation status according to the revised predefined evaluation criteria (>75% = Excellent, 50–75% = Moderate, <50% = Poor). Table 1. Overall NPPCF Implementation Status in Kanker District Overall Score (%) Interpretation 62.5% Moderate Implementation Figure 1. Overall Programme Performance Excellent (>75%) | Moderate (50–75%) |████████████████████ 62.5% Poor (<50%) | The district NPPCF programme demonstrated moderate implementation performance, indicating that essential programme activities were operational and partially functional. However, the score remained below the excellent category, suggesting the need for further strengthening of preventive services, manpower deployment, monitoring mechanisms, and intersectoral coordination to achieve optimal programme effectiveness. 2. Domain-wise Implementation Scores Significant differences were observed among programme components. Diagnostic services had the highest score (83.3%), while intersectoral coordination (48.6%) and IEC activities (50.0%) were among the weakest components. Figure 2. Domain-wise Performance of NPPCF Diagnostic Services ████████████████████████ 83.3 Record Keeping ███████████████████ 71.4 Training █████████████████ 66.7 Logistics ████████████████ 64.5 Monitoring ██████████████ 58.3 Human Resources █████████████ 55.0 IEC Activities ████████████ 50.0 Coordination ███████████ 48.6 Diagnostic and reporting systems were relatively well established. Preventive and administrative functions such as IEC, manpower availability, and coordination with allied departments were comparatively weaker. 3. Prevalence of Fluorosis Among Screened Beneficiaries Among individuals screened under the programme, dental fluorosis was the predominant manifestation, whereas skeletal fluorosis was relatively uncommon. Table 3. Prevalence of Fluorosis Cases Type of Fluorosis Prevalence (%) Dental Fluorosis 45.6 Skeletal Fluorosis 0.7 No Detected Fluorosis 53.7 Dental fluorosis was highly prevalent, indicating chronic fluoride exposure in the community, especially during tooth development years. The lower skeletal fluorosis prevalence may represent either lower chronic cumulative exposure or underdiagnosis. 4. Human Resource Assessment Shortage of dedicated manpower was one of the major operational barriers identified during programme review. Table 4. Human Resource Performance Indicators Indicator Status Vacant sanctioned posts Present Dedicated fluorosis staff Inadequate Multi-tasking burden among staff High Regular field outreach staff Limited Staff shortages adversely affected screening activities, supervision, data reporting, and awareness campaigns. Existing healthcare workers were handling multiple programmes simultaneously. 5. IEC and Community Awareness Activities Information, Education, and Communication (IEC) activities were insufficient in frequency and coverage. Table 5. IEC Activity Assessment IEC Indicator Status Posters/Banners availability Limited Village awareness sessions Irregular School-based education Infrequent Community knowledge of fluorosis Low Figure 4. IEC Functional Status Adequate IEC Coverage ███████ 30% Partial Coverage ████████████ 50% Poor Coverage ███████████████ 70% Low community awareness may reduce utilization of screening services and adoption of preventive measures such as use of safe drinking water sources (Table 4, Fig. 4). 6. Monitoring and Reporting System Although registers and reporting formats were available, delays and irregular supervision were common. Table 6. Monitoring Indicators Indicator Observation Registers maintained Yes Timely monthly reports Inconsistent Supervisory visits Irregular Feedback mechanism Limited The presence of registers reflects structural readiness, but weak supportive supervision and reporting delays can compromise programme efficiency. 7. Major Operational Barriers Identified: Human resource deficit emerged as the most critical barrier, followed by weak IEC outreach and insufficient intersectoral convergence. Table 7. Key Challenges in Programme Implementation Barrier Frequency of Mention Shortage of staff Very High Weak awareness activities High Delayed reporting Moderate Poor interdepartmental coordination High Transport/logistic constraints Moderate Competing programme priorities Moderate F igure 5. Barrier Severity Ranking Staff shortage ███████████████████ Low awareness █████████████████ Poor coordination ███████████████ Delayed reporting ███████████ Transport issues █████████ Competing priorities ████████ 8. Summary of Key Findings • Overall programme implementation score: 62.5% (Moderate) • Best performing domain: Diagnostic Services (83.3%) • Weakest domain: Intersectoral Coordination (48.6%) • Dental fluorosis prevalence: 45.6% • Skeletal fluorosis prevalence: 0.7% • Major barriers: manpower shortage, poor awareness, weak supervision The programme in Kanker district appears structurally functional but prevention-oriented components remain weak. While healthcare facilities are able to diagnose cases, long-term fluorosis control requires stronger manpower deployment, safe water coordination, and sustained community education.

The present study demonstrated moderate implementation of NPPCF in Kanker district with an overall score of 62.5%. Diagnostic services performed relatively well, suggesting that facility-level screening and referral systems were functioning. However, programme effectiveness depends not only on diagnosis but also on prevention, awareness, and environmental interventions. The high prevalence of dental fluorosis (45.6%) indicates sustained fluoride exposure in the population, particularly among children and young adults. Similar findings have been reported from endemic regions of Rajasthan, Gujarat, and Telangana. The low prevalence of skeletal fluorosis (0.7%) may reflect underdiagnosis, lower chronic exposure duration, or limited advanced screening. Human resource shortages significantly affected implementation. Dedicated manpower is essential for outreach screening, data management, and health education. Poor IEC performance in the present study is concerning because behavioral changes such as use of safe water sources and nutritional improvement depend heavily on community awareness. Weak coordination with water supply agencies was another important challenge. Since fluorosis prevention primarily requires access to low-fluoride drinking water, health sector efforts alone are insufficient. Strong convergence between health departments and engineering/public water agencies is critical. Regular monitoring, supportive supervision, and refresher training are necessary to sustain programme quality. Digital reporting systems may improve timeliness and accountability.

NPPCF implementation in Kanker district was moderate. Diagnostic services were satisfactory, but critical gaps existed in manpower, IEC activities, supervision, and intersectoral coordination. The substantial burden of dental fluorosis highlights the need for intensified preventive action. Strengthening workforce capacity, ensuring safe drinking water convergence, expanding awareness campaigns, and improving monitoring mechanisms are recommended. Recommendations 1. Fill vacant posts and deploy dedicated programme staff. 2. Conduct regular refresher training of healthcare workers. 3. Strengthen village-level IEC and school awareness programmes. 4. Improve coordination with PHED for safe water supply. 5. Introduce digital monitoring and monthly review meetings. 6. Expand community screening in endemic villages. Ethical Approval No: No./MC./Ethics/PG/2023/074 Author contributions: All authors are equally contribution in conceptualization, draft writing, data validation and editing, testing. Funding: None Data accessibility: Data information will be provided upon request. Acknowledgments: The authors sincerely thank Dr. R.C. Thakur, CMHO Kanker; Dr. Lokesh Kumar Deo, District Nodal Officer, NPPCF; Dr. Vinod Vaidya, District Consultant, NPPCF; the Chief Health Officer (CHO), Block Medical Officers (BMOs), Medical Officers (MOs), and the District Health Team of Kanker for their valuable support, guidance, coordination, and cooperation during the study. Their assistance in facilitating data collection and providing necessary records was essential for the successful completion of this research. Conflicts of interest: The authors declare that there are no conflicts of interest.

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