Abstract. Introduction. framework for developing a tobacco control intervention that responded to teachers lives in Bihar.

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HEALTH EDUCATION RESEARCH Vol.28 no Pages Advance Access published 4 June 2012 Designing in the social context: using the social contextual model of health behavior change to develop a tobacco
HEALTH EDUCATION RESEARCH Vol.28 no Pages Advance Access published 4 June 2012 Designing in the social context: using the social contextual model of health behavior change to develop a tobacco control intervention for teachers in India Eve M. Nagler 1, Mangesh S. Pednekar 2, Kasisomayajula Viswanath 1,8, Dhirendra N. Sinha 3,MiraB.Aghi 4, Claudia R. Pischke 5, Cara B. Ebbeling 6, Harry A. Lando 7, Prakash C. Gupta 2 and Glorian C. Sorensen 1,8 1 Center for Community Based-Research, Dana-Farber Cancer Institute, Boston, MA 02115, USA, 2 Healis-Sekhsaria Institute for Public Health, Navi Mumbai , India, 3 School of Preventive Oncology, Patna , India, 4 Consultant, Healis- Sekhsaria Institute for Public Health, New Delhi , India, 5 Institute for Epidemiology and Prevention Research (BIPS), Bremen, 28359, Germany, 6 Division of Endocrinology, Children s Hospital, Boston, MA 02115, USA, 7 Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN 55454, USA and 8 Department of Society, Human Development and Health, Harvard School of Public Health, Boston, MA 02115, USA *Correspondence to: E. M. Nagler. Received on October 28, 2010; Accepted on April 3, 2012 Abstract This article provides a theory-based, step-by-step approach to intervention development and illustrates its application in India to design an intervention to promote tobacco-use cessation among school personnel in Bihar. We employed a five-step approach to develop the intervention using the Social Contextual Model of Health Behavior Change (SCM) in Bihar, which involved conducting formative research, classifying factors in the social environment as mediating mechanisms and modifying conditions, developing a creative brief, designing an intervention and refining the intervention based on pilot test results. The intervention engages users and non-users of tobacco, involves teachers in implementing and monitoring school tobacco control policies and maximizes teachers role as change agents in schools and communities. Intervention components include health educator visits, discussions led by lead teachers, cessation assistance, posters and other educational materials and is implemented over the entire academic year. The intervention is being tested in Bihar government schools as part of a randomized-controlled trial. SCM was a useful framework for developing a tobacco control intervention that responded to teachers lives in Bihar. Introduction The global burden of tobacco-related mortality is increasingly shifting to low- and middle-income countries. Approximately 82% of the world s 1.1 billion smokers are found in low- and middleincome countries, and by 2030, it is estimated that 80% of the world s 8 million tobacco-related deaths will occur in these countries [1 3]. Systematically working towards decreasing and abolishing production of tobacco and tobacco products, banning tobacco use in public places and educational institutions, increasing taxation on tobacco through fiscal measures, preventing uptake of tobacco use by adolescents and children, and addressing cessation among tobacco users are some of the recommended strategies to decrease tobacco use [4]. Tobacco prevention and cessation interventions that address the social context, which includes life experiences, social relationships, organizational structures and societal influences, have been shown to be meaningful and relevant to the intended ß The Author Published by Oxford University Press. All rights reserved. For permissions, please doi: /her/cys060 E. M. Nagler et al. audiences [5, 6] as well as effective at changing health behaviors that can reduce the risk of developing chronic diseases [7 9]. However despite this need, few intervention development or planning models exist [10 15] that integrate multiple theories and help practitioners design interventions in a step-by-step manner. Social and behavioral theories, such as the Social Cognitive Theory, have been broadly used to inform interventions in low- to middle-income countries, including India [16 18]. This study was guided by the Social Contextual Model of Health Behavior Change (SCM), which has been applied mainly in the United States [5, 6, 19]. SCM was developed by researchers at the Dana-Farber Cancer Institute (DFCI) and the Harvard School of Public Health (HSPH) in early 2000 to guide their work to design cancer prevention interventions [5, 7, 8, 20 23]. The model is based on a rich foundation of social and behavioral research as well as lessons from social epidemiology. It includes psychosocial factors found to be predictive of behavior change, including self-efficacy, attitudes and beliefs, intentions to perform a behavior and the skills needed to do it. SCM also delineates pathways through which population characteristics, such as income or education, influence health behaviors. Interventions using this model classify factors found in the social environment as either modifying conditions or mediating mechanisms. Modifying conditions are those factors, which may independently affect outcomes but are not influenced by the intervention; mediating mechanisms refer to those factors, which are amenable to change, and are addressed by the intervention. Given that interventions developed based on SCM have been shown to significantly reduce tobacco use and other risk-related behaviors in the United States [7 9, 22], we believed it would be a highly relevant model to guide intervention development in low- to middle-income countries. We therefore used SCM to develop a school-based tobacco cessation intervention for teachers in India, marking it as the first effort to our knowledge to apply the model found effective in Western cultures to another setting. The purposes of the article are to (i) provide a step-by-step approach to intervention development using SCM and (ii) illustrate its application in the Bihar School Teachers Study (BSTS) a study designed to promote tobacco-use cessation among school personnel in the Indian state of Bihar. Teachers are the focus of BSTS because as role models for youth and key opinion leaders related to community norms [24 27], they represent an important group for tobacco control. Methods Study design BSTS is a collaboration between Healis-Sekhsaria Institute for Public Health (Healis) in Mumbai and Patna, India and DFCI and HSPH in the United States. BSTS used a cluster randomized-controlled design to assess the extent to which a comprehensive tobacco control intervention results in: (i) tobaccouse cessation among teachers and (ii) implementation of school tobacco control policies. The intervention was conducted in two waves over two consecutive academic years ( ). In this article, we describe how SCM was used to develop the BSTS intervention from January 2008 (the second half of the academic year) through January Study setting and population The state of Bihar is located in northern India and has a population of around 83 million [28]. On a broad range of indicators of socio-economic well-being, Bihar had far fewer resources and social infrastructure than most other states in India. For example, according to the 2001 Census of India, only 4% of Bihar households had tap drinking water compared to the national average of 37% [28]. Bihar is a major tobacco producing state and has a higher prevalence of tobacco use compared to the national average (Table I) [29, 30]. Tobacco use is also high among teachers; according to the Global School Personnel Survey (GSPS) conducted in 2000, 78% of teachers in Bihar used some form of tobacco [27]. For BSTS, we randomly selected Tobacco control intervention for teachers in India Table I. Comparison of indicators of socio-economic well-being, India and Bihar Indicator India Bihar Literacy rate a 74.0% 63.8% Infant mortality rates per 1000 births b Percent of workers employed as agricultural laborers c 26.5% 48.0% Percent of households with tap as source of drinking water c 36.7% 3.7% Percent of households with electricity as sources of lighting c 55.8% 10.3% Percentage of males age 15 and above who are current tobacco users d 47.9% 66.2% Percentage of females age 15 and above who are current tobacco users) d 20.3% 40.1% Percentage of males age 6 and over who received no education b 21.9% 35.3% Percentage of females age 6 and over who received no education b 41.5% 60.3% Percentage of males who are currently employed b 84.5% 78.6% Percentage of females who are currently employed b 36.3% 23.5% a Census of India, 2011 [52]. b National Family Health Survey (NFHS-3) [53]. c Census of India, 2001 [28]. d Global Adult Tobacco Survey (GATS) India Report [30]. rural and urban schools representing grade levels 8 10 from a total of 6900 schools governed by Bihar state government. To be eligible for the study, schools had to have eight or more teachers and not located in flood zones. (Flooding causes schools to close, which would prohibit us from implementing the intervention.) Thirty-six schools were randomly assigned to the intervention group and the remaining 36 were assigned to the delayed intervention control group. For the sub-study we designed to develop the BSTS intervention, we purposively sampled 110 teachers to participate in three sets of focus groups. These teachers were from rural and urban Bihar government schools, taught grade levels 8 10 and represented the same demographics as teachers from study schools, but were not from the 72 schools selected for the randomized trial. The Indian Council of Medical Research along with Healis and the HSPH Institutional Review Boards approved BSTS procedures. Five-step SCM intervention development process Using SCM to develop the BSTS intervention involved five steps: (i) conducting formative research; (ii) classifying factors in the social environment as mediating mechanisms or modifying conditions; (iii) developing a creative brief; (iv) designing an intervention and (v) refining the intervention based on pilot test results. The actions needed for each step are presented in Fig. 1 and the application of them is described in the Results section. Research methods Data collection Review of literature and archival data. Reviewing the literature serves as the first step in intervention development, thereby grounding the process in prior research evidence. Our research team consisted of communication scientists, epidemiologists and social and behavioral scientists from India and the United States. In Step 1, we reviewed the findings of prior research our team conducted in related to school tobacco control policies and tobacco-use patterns among teachers in Bihar; this, in turn, informed the questions we would ask teachers in focus groups [27, 31]. We also reviewed the results of other tobacco-related research conducted in India and obtained demographic data from the Bihar Education Department about teachers in our study schools [32 34]. Focus groups. We conducted focus groups as part of three different steps outlined in Fig. 1: Step 1 (January 2008), Step 3 (June 2008) and Step 5 115 E. M. Nagler et al. Fig. 1. SCM Intervention Development Process and timeline followed in BSTS. (January 2009). Table II summarizes the number and composition of these groups along with key themes that arose from the analyses. Each group had a mix of male and female teachers as well as users and non-users of tobacco. All focus groups lasted between 60 and 90 min and were guided by scripts based on stated research objectives (Table III). Staff members were trained to moderate the focus groups and were assisted by trained note takers who took careful, systematic notes during each discussion. All focus groups were audiorecorded, conducted in Hindi and translated into English immediately afterwards. Notes were also transcribed immediately following each group and compared as needed to the audio recordings to assure completeness of the data. Direct observations. In Step 1, teams of two BSTS staff members traveled to each study school in July to September 2008 to observe school conditions using a standard checklist. Conditions included the presence of a principal s office, a staff room and the distance of each school from the Patna study office. We also observed the types of health-related materials in the schools and the placement of important information for teachers, such as notices from the principal. These observations would help us determine what intervention activities and materials would be appropriate for this context. Data analysis All data were analyzed based on standard qualitative research methods [35 37]. We also used an iterative data analysis process, in which each step of the process informed the others. Key findings from our literature review were summarized in a creative brief (Step 3). The transcribed focus group data were analyzed using a two-stage coding process: Level 1 structural coding and Level 2 thematic coding. Structural coding followed the structure of the focus group guide, in which the response to every question received a structural code. Thematic coding was based on themes that arose from the structural coding, and was applied in a second pass analysis. These methods were enhanced by the use of N Vivo software (QSR International). The analysis of the 116 Tobacco control intervention for teachers in India Table II. Composition and themes from focus groups conducted with teachers to develop the Bihar School Teacher s Study intervention Date and Purpose Number of groups Composition Key themes from focus groups January 2008 To better understand the social context of tobacco use from teachers perspective June 2008 To test intervention components and delivery approaches Four N ¼ 44 Male: 31 Female: 13 Urban: 15 Rural: 29 Users: 2 Non-users: 17 Unknown: 25 Three N ¼ 32 Male: 25 Female: 7 Urban: 13 Rural: 19 Users: 14 Non-users: 18. Teachers were more likely to use tobacco outside of school, and if they used it, they were more likely to use smokeless products. There were social pressures to use tobacco at weddings, festivals and other ceremonies. Perception that more men than women used tobacco. Belief that less-educated people used more tobacco because they were unaware of the harmful effects. Tobacco was used to deal with daily stress and tension, as well as to make them fresh. Misconception that tobacco enhances energy. Being a role model for students, pressure from family members, teachers status in society, and cost were key reasons for quitting. Job structure (gap between classes) resulted in boredom and tobacco use for some teachers. Will power, family influences and social support from co-workers were essential for quitting. Using sauf (fennel seeds) or cardamom, diverting one s mind by reading books or magazines and meditation were suggested quit strategies. Story-telling of how other people quit could also enhance quitting. School tobacco policies existed but were not enforced. Principals were pivotal in supporting and enforcing school tobacco policies. A lead teacher should be selected to serve as program liaison and host monthly meetings. Signage about school tobacco policies should be highly visible. Resource materials should be kept in a central place, such as a resource center. Information about tobacco should: (i) be scientific yet practical; (ii) stress the harmful effects of it; (iii) outline the steps for quitting; (iv) provide stories of successful quitters. Because teachers wanted to help family and friends quit tobacco, they wanted materials they could take home. Family support for quitting should be integrated into intervention materials, components and discussion groups about tobacco. Teachers should engage in regular discussions about tobacco, which could also build support for quitting. Having monthly visits from an outside health expert, such as a health educator, would add credibility and enthusiasm for a tobacco program. Principals should be engaged throughout the program to ensure success January 2009 Two N ¼ 34. Discussions about tobacco were key to promoting cessation (continued) 117 E. M. Nagler et al. Table II. Continued Date and Purpose Number of groups Composition Key themes from focus groups To obtain teachers reactions to the 3-month pilot test of the intervention Male: 15 Female: 14 Unknown: 5 Urban: 22 Rural: 12 Users: 4 Non-users: 25 Unknown: 5. Some women (who were non-users) did not feel the program was relevant for them. Lack of awareness that a tobacco control policy was being formulated for their schools. Desire for action-oriented information about tobacco cessation or staying tobacco-free that teachers could use to help family members quit. Objection to the program name ( Tobacco-Free Teachers ) because it shamed teachers in front of their students. Intervention did not clearly communicate the role that other teachers, especially non-users, could play in helping other people quit thematic data culminated in a Themes Document that summarized the major themes from the focus groups and contributed to the development of a creative brief. Direct observation data collected at schools were arranged into Field Note binders and referenced throughout the intervention development process. Throughout data analysis, our research team met regularly (in person and by phone) to interpret the data and determine how it would be used to inform the intervention. Results Step 1: conduct formative research Formative research, which includes literature reviews, focus groups and direct observations, is an integral part of using SCM to guide the intervention development process [38, 39]. Using these methods, we collected teachers demographic data as well as information on their social context at five levels of influence (individual, interpersonal, organizational, neighborhood or community and societal). From previous research our team conducted in India, we noted a higher prevalence of tobacco use in schools without a tobacco control policy as compared to schools with a policy [27]. Additionally, the literature revealed many tobacco myths, such as chewing tobacco being good for teeth and gums. We also learned through literature and census data that teachers are relatively advantaged and well educated compared to the rest of their community. They are government employees, receive regular salaries and most of them have at least some college education. Thus, the intervention materials could be written at a relatively high reading level and would be in Hindi, the official language of Bihar. Despite the Global School Personnel Survey findings that 78% of male and female teachers used tobacco, there was a strong perception among the January 2008 focus group participants that overall use was higher among men than women, and likely lower than that reported in GSPS. Participants reported male teachers mainly used smokeless tobacco such as khaini (a mixture of chewing tobacco and lime) and paan (betel leaf filled with sliced areca nut, lime, tobacco and other condiments) outside of school, whereas lady teachers occasionally chewed paan at social events, and older female teachers used gul (powdered tobacco) at home. Related to policy, female teachers were more likely than male teachers to recommend punitive approaches to enforce no tobacco use, such as fining teachers for using tobacco on campus. From direct observations of schools, we learned many did not have electricity or a staff room. Additionally, we found tobacco products present on school grounds, indicating school tobacco 118 Tobacco control intervention for teachers in India Table III. Focus group moderator guides January 2008 Motivation for teacher tobacco use, including social norms (1) Do any of you use tobacco? If yes, what type(s) of tobacco do you use? (2) What do you like about tobacco? What do you dislike about it? (3) When do you typically use tobacco? Do you use different types of tobacco at differ
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