The effects of an education program on hookah smoking cessation in university students: an application of the Health Action Process Approach (HAPA)

The effectiveness of a theory -based health education program on waterpipe smoking cessation in Iran: one year follow-up of a quasi-experimental research

BACKGROUND

The present research aimed to determine the effect of an educational intervention based on the extended theory of planned behavior (ETPB) on waterpipe (WT) smoking cessation in women.

METHODS

The present quasi-experimental had a pre-test, post-test design with 3, 6 and 12 months follow-ups was conducted in Bandar Abbas city, south of Iran in December 2021-March 2023. A total of 448 women over the age of 15 (224 in the intervention group (IG), 224 in the control group (CG)), using a two-stage cluster sampling method participated. The educational intervention focused on WT smoking cessation implemented in 14 sessions. The educational methods in the training sessions were lectures, collaborative discussions, Q&As, brainstorming, role plays, and peer education. The main outcome was WT cessation behavior. Repeated measures ANOVA tests and post hoc were run to compare the IG and CG at baseline in terms of demographic variables, t-test and chi square test, and in the four points of time of data collection. The data were analyzed in Stata14. A p-value < 0.05 was considered as statistically significant.

RESULTS

The mean and standard deviation of WT cessation behavior and all ETPB constructs in the IG was significantly higher than the CG. After the educational intervention, in the IG, the perceived behavioral control, attitude, subjective norm, intention and knowledge increased, and the weekly smoking and WT smoking habit decreased (P < 0.001). The CG did not have any significant change in other variables except for the increased knowledge score. During the 12-month follow-up, the cessation rate was 43.81% (P = 0.645) in the IG and 7.45% in the CG (P = 0.081).

CONCLUSIONS

The educational intervention positively affected WT smoking reduction and cessation in women through influencing the ETPB constructs. It is strongly recommended to design theory-based interventions beyond the individual level with an emphasis on interpersonal relationships to facilitate WT cessation as far as possible.

Development and psychometric assessment of Health Action Process Approach (HAPA) in terms of smoking cessation among Chinese smokers

The Health Action Process Approach (HAPA) is a two-stage (pre-intentional and post-intentional) behavioral change model that distinguishes between motivation and volition in behavior change process. This study aims to develop HAPA-based assessments for smoking cessation among current smokers. The HAPA-based measures were developed and the draft measures included nine constructs, namely, risk perception in smoking-induced cancer, risk perception in smoking-induced systemic disease, positive outcome expectancy, negative outcome expectancy, self-efficacy in quitting smoking, self-efficacy in maintaining, self-efficacy in re-initiating, quitting planning and coping planning in smoking cessation, with a total of 26 items. A cross-sectional survey was conducted in China in 2022. Principal Component Analysis was used for Exploratory Factor Analysis (EFA). Cronbach's α coefficient was calculated to evaluate the internal consistency. Variables such as severity of smoking addiction were selected to evaluate the correlation between the HAPA scale and these variables. Of the 928 participants, 76.4% (709/928) were male and the median age was 35 years. Five factors were extracted by EFA. The factor loadings of each item were all greater than 0.60, and the cumulative variance contribution rate was 90.15%. The Cronbach's α coefficient of each HAPA-based subscales was 0.929-0.986. The HAPA-based measurements are comprehensive, reliable and valid in the assessment of smokers' smoking cessation cognition, which can be used to guide the design and implementation of intervention and the development of theory.

The effect of nutritional education based on the health action process approach (HAPA) on the pregnancy outcomes among malnourished pregnant mothers

OBJECTIVE

To examine the effectiveness of nutritional education based on the health action process approach (HAPA) on pregnancy outcomes among malnourished pregnant mothers utilizing nutritional support.

METHODS

In a randomized controlled trial, 234 malnourished pregnant women under nutritional support from the fourth month of pregnancy participated. Participants were randomly allocated in study groups by the balance block randomization method. Data were collected using a socio-demographic and pregnancy outcomes checklist as well as self-devised questionnaire assessing the constructs of the HAPA model before and three months after the educational intervention. The framework of the educational intervention was based on the constructs of the HAPA and included three one-hour training sessions through lectures, group discussions, 'question and answer' sessions, and the use of educational tools. Data were analyzed using analysis of covariance (ANCOVA) and SPSS software.

RESULTS

Pregnancy outcomes including optimal weight gain during pregnancy (p = 0.47), neonate's birth weight (p = 0.58), gestational age at delivery (p = 0.83), type of delivery (p = 0.48) gestational anemia (p = 0.22), diabetes (p = 0.59) and hypertension (p = 0.29) were not significantly different in the intervention and control groups. The results showed that the educational intervention produced a significant increase in the total score (24 points) in the intervention group. Improvement of scores in the intervention group compared to the control was observed in all of the model constructs except outcome expectation (0.68 decrease). The educational intervention in the present study had a large measure of effect in total (SMD: 2.69, partial eta2: 0.664).

CONCLUSION

A nutritional education intervention based on the HAPA model for malnourished pregnant women increased behavioral intention and planning for action to have better nutritional behavior. However, the intervention did not change the pregnancy outcomes significantly.

PRACTICE IMPLICATIONS

Nutritional education based on the HAPA model can be used to improve nutritional behaviors of malnourished pregnant women.

Interventions for waterpipe smoking cessation

BACKGROUND

While cigarette smoking has declined globally, waterpipe smoking is rising, especially among youth. The impact of this rise is amplified by mounting evidence of its addictive and harmful nature. Waterpipe smoking is influenced by multiple factors, including appealing flavors, marketing, use in social settings, and misperceptions that waterpipe is less harmful or addictive than cigarettes. People who use waterpipes are interested in quitting, but are often unsuccessful at doing so on their own. Therefore, developing and testing waterpipe cessation interventions to help people quit was identified as a priority for global tobacco control efforts.  OBJECTIVES: To evaluate the effectiveness of tobacco cessation interventions for people who smoke waterpipes.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Review Group Specialized Register from database inception to 29 July 2022, using variant terms and spellings ('waterpipe' or 'narghile' or 'arghile' or 'shisha' or 'goza' or 'narkeela' or 'hookah' or 'hubble bubble'). We searched for trials, published or unpublished, in any language.

SELECTION CRITERIA

We sought randomized controlled trials (RCTs), quasi-RCTs, or cluster-RCTs of any smoking cessation interventions for people who use waterpipes, of any age or gender. In order to be included, studies had to measure waterpipe abstinence at a three-month follow-up or longer.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcome was abstinence from waterpipe use at least three months after baseline. We also collected data on adverse events. Individual study effects and pooled effects were summarized as risk ratios (RR) and 95% confidence intervals (95% CI), using Mantel-Haenszel random-effects models to combine studies, where appropriate. We assessed statistical heterogeneity with the I2 statistic. We summarized secondary outcomes narratively. We used the five GRADE considerations (risk of bias, inconsistency of effect, imprecision, indirectness, and publication bias) to assess the certainty of the body of evidence for our primary outcome in four categories high, moderate, low, or very low.

MAIN RESULTS

This review included nine studies, involving 2841 participants. All studies were conducted in adults, and were carried out in Iran, Vietnam, Syria, Lebanon, Egypt, Pakistan, and the USA. Studies were conducted in several settings, including colleges/universities, community healthcare centers, tuberculosis hospitals, and cancer treatment centers, while two studies tested e-health interventions (online web-based educational intervention, text message intervention). Overall, we judged three studies to be at low risk of bias, and six studies at high risk of bias. We pooled data from five studies (1030 participants) that tested intensive face-to-face behavioral interventions compared with brief behavioral intervention (e.g. one behavioral counseling session), usual care (e.g. self-help materials), or no intervention. In our meta-analysis, we included people who used waterpipe exclusively, or with another form of tobacco. Overall, we found low-certainty evidence of a benefit of behavioral support for waterpipe abstinence (RR 3.19 95% CI 2.17 to 4.69; I2 = 41%; 5 studies, N = 1030). We downgraded the evidence because of imprecision and risk of bias. We pooled data from two studies (N = 662 participants) that tested varenicline combined with behavioral intervention compared with placebo combined with behavioral intervention. Although the point estimate favored varenicline, 95% CIs were imprecise, and incorporated the potential for no difference and lower quit rates in the varenicline groups, as well as a benefit as large as that found in cigarette smoking cessation (RR 1.24, 95% CI 0.69 to 2.24; I2 = 0%; 2 studies, N = 662; low-certainty evidence). We downgraded the evidence because of imprecision. We found no clear evidence of a difference in the number of participants experiencing adverse events (RR 0.98, 95% CI 0.67 to 1.44; I2 = 31%; 2 studies, N = 662). The studies did not report serious adverse events.   One study tested the efficacy of seven weeks of bupropion therapy combined with behavioral intervention. There was no clear evidence of benefit for waterpipe cessation when compared with behavioral support alone (RR 0.77, 95% CI 0.42 to 1.41; 1 study, N = 121; very low-certainty evidence), or with self-help (RR 1.94, 95% CI 0.94 to 4.00; 1 study, N = 86; very low-certainty evidence).  Two studies tested e-health interventions. One study reported higher waterpipe quit rates among participants randomized to either a tailored mobile phone or untailored mobile phone intervention compared with those randomized to no intervention (RR 1.48, 95% CI 1.07 to 2.05; 2 studies, N = 319; very low-certainty evidence). Another study reported higher waterpipe abstinence rates following an intensive online educational intervention compared with a brief online educational intervention (RR 1.86, 95% CI 1.08 to 3.21; 1 study, N = 70; very low-certainty evidence).  AUTHORS' CONCLUSIONS: We found low-certainty evidence that behavioral waterpipe cessation interventions can increase waterpipe quit rates among waterpipe smokers. We found insufficient evidence to assess whether varenicline or bupropion increased waterpipe abstinence; available evidence is compatible with effect sizes similar to those seen for cigarette smoking cessation.  Given e-health interventions' potential reach and effectiveness for waterpipe cessation, trials with large samples and long follow-up periods are needed. Future studies should use biochemical validation of abstinence to prevent the risk of detection bias. Finally, there has been limited attention given to high-risk groups for waterpipe smoking, such as youth, young adults, pregnant women, and dual or poly tobacco users. These groups would benefit from targeted studies.

The effectiveness of tobacco cessation programs for university students: A systematic review and meta-analysis

INTRODUCTION

This systematic review and meta-analysis aimed to explore the existing tobacco interventions and synthesize whether those interventions affected tobacco use among university students.

METHODS

We searched and found 1799 studies in PubMed, ClinicalKey for Nursing, Embase, and SCOPUS between 2009 and 2022. The risk of bias was assessed using similar criteria for RCT and non-randomized studies guided by the Cochrane Handbook for Systematic Reviews. The heterogeneity of studies was evaluated using Cochran's Q and I² index. The GRADE system was used to distinguish the quality of evidence, and Egger's linear regression test was performed to assess publication bias.

RESULTS

Eighteen studies used data extraction and analyses, and only eleven were meta-analyzed, which found that the estimate obtained via the fixed-effects model was statistically significant. Technology-based and motivational interview interventions found pooled ORs of statical significance, while reinforcer interventions showed the smallest effect size. The level of heterogeneity was considered substantial. The assessment for quality of evidence showed low overall certainty of evidence due to imprecision of outcome and suspicion of publication bias. Egger's test showed no publication bias among included studies (p=0.38).

CONCLUSIONS

There were numerous tobacco cessation interventions for university students, but the most effective intervention to change tobacco consumption behavior was still inconclusive and uncertain.

TRIAL REGISTRATION

This systematic review was registered with PROSPERO. The registration number is CRD42019142491.

Using intervention mapping for hookah smoking cessation: a quasi-experimental evaluation

Background

The present study aimed to evaluate the results of a theory-based and systematic intervention on Hookah Tobacco Smoking (HTS) cessation in women local to Bandar Abbas, Iran.

Methods

In the present quasi-experimental research, we used an intervention mapping approach to develop, implement, and evaluate an education and training course as our intervention. Applying the results of a systematic review and two prior local qualitative studies, we identified six HTS determinants and set goals for the intervention. We selected 212 eligible women through systematic stratified random sampling and enrolled them in control and intervention groups. The course was presented to the intervention group in 17 sessions for four months. The educational material was developed to address the goals of the intervention, improve HTS determinants, and change the HTS behavior. We used a questionnaire to collect data on participants’ characteristics, HTS behavior, and detailed determinants of HTS in the control and intervention groups at the beginning of the study, at the end of the intervention, and at three- and six- months follow-up. All work done in the study was guided by ethical considerations.

Results

The results showed no significant difference between women enrolled in control and intervention groups regarding participants’ characteristics and HTS behavior. At baseline, there were no differences between groups for six determinants of HTS (knowledge, attitude, social norms, self-efficacy, habit, and intention). At the end of the intervention and at three and six months follow-up, the women in the intervention group had significantly better results in all six domains, compared with those in the control group. The rate of HTS abstinence at the end of the intervention and at the three- and six-month follow-ups was 61.3%, 48.5%, and 45.5% for the intervention and 16%, 14.4%, and 10% for the control groups, respectively.

Conclusions

HTS is a complicated behavior, and its cessation is hard. However, Intervention Mapping (IM) can be a powerful integrative, purposeful, theory-based, and participation-based method to reduce or cease HTS. This method should be tested in other settings.

Trial registration: IRCT20190126042494N1, Registered 3.3.2019. https://en.irct.ir/trial/37129

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-022-00287-5.

Understanding the continuous vaccination of the COVID-19 vaccine: an empirical study from China

Vaccination for the novel coronavirus disease 2019 (COVID-19) provides an effective approach for the general improvement of social safety and individual health. However, given that the current COVID-19 vaccine can only work for a period of time, the continuous vaccination of the vaccine will be particularly important. Using the Health Action Process Approach (HAPA) Model, Expectation Confirmation Model (ECM) and vaccine hesitancy (VH) theory, this research evaluates the continuous vaccination for COVID-19. This research selected Chinese survey platform to recruit respondents and conducted online surveys. A total of 768 Chinese individuals who were vaccinated participated in the survey, and 561 responses were effective after screening. Six valuable and novel findings are identified through this research. First, perceived efficacy has a positive significant impact on vaccination intention, but the positive effects of outcome expectancy and risk perception on vaccination intention are not significant. Second, social positive cues play a significant role in promoting vaccination intention. Third, VH has a negative significant influence on vaccination intention. Fourth, vaccination behavior produces a positive significant effect on perceived usefulness and satisfaction, respectively. Fifth, perceived usefulness exerted a positive significant impact on satisfaction and continuous vaccination, respectively. Sixth, satisfaction has no positive significant influence on continuous vaccination. Our theoretical model, which is the main contribution of this research, indicates that individual continuous vaccination is a process from motivation to intention, and from intention to behavior, and then from behavior to continuous vaccination.

Geographic distribution and time trends of water-pipe use among Iranian youth and teenage students: A meta-analysis and systematic review

Water-pipe tobacco smoking is harmful to health, yet its rate of prevalence remains uncertain. Recent evidence has shown that the prevalence of water-pipe smoking among students is higher than in the general population. In this study, a systematic review of related literature on water-pipe use was conducted, and for this purpose, 76 articles were examined in the study. In this vein, geographic distribution and time trends of water-pipe consumption in Iran were considered. The results of this study showed that lifetime, last-year, and last-month prevalence of water-pipe smoking use among Iranian students were 28.78 (25.07-32.49), 20.84 (16.01-25.66), and 16.36 (11.86-20.85), respectively. The results also showed a wide variation by the region and sex in Iran. This study has shown the importance of addressing public prevention and alerting programs in schools and universities.

What are the intervention goals of women's hookah cessation? A systematic, evidence-based and participatory study

This Study was designed to answer the question: what are the intervention goals of women for ceasing to smoke. The present research was part of a larger study and was a pioneering systematic research conducted between September 23, 2018 and September 26, 2019 through an intervention mapping in southern Iran among professional hookah Smoking (HS) women. In order to know more about the HS among women, the behavioral and environmental correlates of HS/cessation and the determiners or fundamental causes of these factors were extracted via a systematic review and a local qualitative study. As the results revealed, the expected outcomes of the educational program concerning hookah cessation were achieved. As the realization of these outcomes requires certain changes to the behavioral and environmental dimensions, in the next step, the intervention goals of hookah cessation were identified. As the results showed, four behavioral factors involved in the unhealthy HS behavior were individual HS, Being in the Company of hookah smokers, Visiting tempting and contaminated places and Physical and mental dependence on HS (habit), In addition, four effective environmental factors were found at different interpersonal, organizational, community and policy levels. These include, respectively: recommendation and motivation for cessation by influential figures, care providers' poor inadequate knowledge and skill, Easy acceptance of hookah in society, and the lack of effective rules. Knowledge, awareness, social norms, Motivation to comply, skill and self-efficacy, habit, were among the determining factors of hookah cessation. Employment of a systematic is based on evidence and cooperation and is guided by a assessing the needs of the target population. Such a method can suggest more purposive and relevant intervention goals so as to cease HS. The aim would be to intervene in the purposes of the above-mentioned change, as compared in predetermined interventions, and increase the chances of HS cessation among women.

Development and Validation of an Instrument to Measure Parental Factors Related to Substance Use Prevention in Adolescents

BACKGROUND

The average age of using illicit drugs for the first time in adolescents has decreased in Iran over the past years. Studies show that family and environment play a notable role in keeping adolescents away from substances.

AIMS

The present study is an attempt to develop and validate a model-based questionnaire to measure parental factors related to substance use prevention in adolescents.

METHODS

This methodological study was carried out on 336 parents of high school students in Sabzevar- Iran, in 2018. The first draft of the questionnaire, including 136 items, was developed based on the constructs of the Health Promotion Model (HPM) using similar questionnaires, literature review, and interviewing 9 qualified experts. The validity of the questionnaire was measured through face validity (qualitative and quantitative), content validity (qualitative and quantitative), and construct validity (confirmatory factor analysis). The reliability of the questionnaire was measured by internal consistency and test-retest reliability. SPSS ver. 16 and LISREL ver. 8.2 software was used for statistical analysis.

RESULTS

Throughout the validation process, 35 items were omitted, and the final version of the questionnaire consisting of 101 items was developed. The overall content validity ratio was 0.81, which indicates the proper and understandable content of the items. The overall content validity index was 0.96, which indicates excellent expert validity. The Cronbach's alpha coefficient of the questionnaire was 0.85 (constructs range= 0.73-0.96), and the intraclass correlation coefficient of the questionnaire was 0.78 (constructs range= 0.46-0.91), which indicates that the questionnaire has good internal consistency and test-retest reliability. Further, the confirmatory factor analysis yielded an appropriate fit for the model (RMSEA= 0.069, χ2/df= 2.77, GFI= 0.60, AGFI= 0.83, CFI= 0.83, NNFI= 0.83).

CONCLUSION

The validity and reliability of the HPM-based questionnaire were supported. Therefore, the questionnaire can be used by health educators and health policymakers in empowerment programs for parents to improve their behavioral skills concerning the prevention of substance use in their adolescents.