Background
Methods
Study setting and participants
Sample size
Selection of GN areas and randomization
Selection of households in a cluster
Primary outcome measure and the operational definition
Secondary outcomes
-
exposure of women to SHS within the last 30 days prior to the data collection
-
knowledge of women on health risk of exposure to SHS
-
attitudes of women towards exposure to SHS, right to smoke free living and women empowerment against smoking
-
Observed evidence on smoking inside houses
Outcome measurements
Development of intervention
Household exposure to SHS among women- Theoretical framework
Reinforcement: reinforcing the knowledge of the women on the health effects of SHS and third hand smoking, positive attitudes towards right to smoke free living and environmental factors (social norms, role models, social support, opportunities).
Perceived susceptibility: belief of the women that even though they have no symptoms due to SHS, they are susceptible to short and long term health effects of SHS.
Cues to action: display of posters and stickers might encourage women to maintain smoke free homes.
Expectation, benefits and barriers: learn how smoke free homes benefit them and their families and to overcome barriers of making a household SHS free.
Empowerment: empowering women to exercise their right to smoke free living. Develop social support group against SHS within their locality. Schoolchildren to act as change agents to educate their mothers/women in their households and declare smoke free homes.
Observational learning: select role models of women living in smoke free houses within their GN area.
Behavioral capacity: improve skills of women on the actions to be taken if somebody smokes inside the home and to exercise their right to smoke free living.
Self-efficacy: volunteers and Public Health Midwives (PHMs) encourage women to set targets to achieve smoke free homes and in turn to accept right to smoke free living as a value and social norm. |
Interventions and implementation
Training of field staff who provide services to residents of the GN divisions
Three training workshops were organized at Bulathsinghala MOH office for the field workers of health, non-health and volunteers of all the GN divisions who were selected for the intervention. The importance of declaring the houses of the study population as smoke free homes were targeted. The field staff who provide services to adults by means of home visits or in clinics/offices were chosen based on their opportunities to interact with the women to provide the knowledge. The health staff included MOH, PHM, Public Health Inspectors, and non-health staff included Grama Niladari, Samurdi Officer, Social Service Officer and health volunteers. Additionally, the training was aimed at gaining support of the officers for a larger research. We used adult training methods such as lecture discussion, group work, group discussion, role play, experience sharing sessions in the workshop. A video developed by the Ministry of Health on health effects of SHS was also shown to them. The Principle Investigator conducted the training workshops along with a legal officer for a non-governmental organization called Alcohol and Drug Information Centre who deals against tobacco and alcohol.
Individual and group health education sessions for women.
Intervention was in the form of individual and interactive small group health education sessions. Two trained volunteers were selected from each cluster in a GN division and were trained to deliver the health education sessions. Selected volunteers were the active members of the mother support group, which is a strong volunteer organization to strengthen the community level health promotion activities in Sri Lanka. Each volunteer was asked to visit the half of the households [12, 13] of the group of women selected from a GN division for the intervention. Intervention was done with the PHM who was also trained to deliver the intervention as described earlier. The volunteers organized small group discussions with the women and invited the area PHM. The area PHM initiated discussion on family wellbeing as an entry point in the discussion and thereafter conducted the discussion to identify the problems faced by the women in relation to being exposed to SHS. Women were educated how to apply avoidance behaviour when exposure to SHS, such as walking away from SHS, showing displeasure against exposure to SHS. Identified problems were prioritized and the two-trained volunteers with inputs from the women and the area PHM developed a problem and solution tree. Special attention was given to educate women on health effects of exposure to SHS and the right to smoke free living. Leaflets and stickers were distributed among women. They were persuaded to implement 100% smoke free environment in their homes. The women were guided to decide how they could reduce exposure to SHS, as applicable to their own home. Modalities like demonstration, role-playing, storytelling and sharing experience were used to educate and motivate them to initiate activities. Each group discussion lasted for about one and a half hours. The two health volunteers noted down the interventional activities selected by women. Those included discussions with their spouses on health effects of passive smoking, SHS exposure avoidance behaviour, and display stickers on “this house is tobacco smoke free”. In addition, women themselves initiated some activities, which were not directly related to SHS reduction, but improved family well-being by strengthening family bond. They were household money management, home gardening, proper garbage disposal, hygienically safe kitchen, family dinners and religious activities, etc. When women became empowered by creating changes within their own home, they visited neighborhood homes too, to explore the possibility of spreading the results to the community away from the household. Initially PHM and the volunteers motivated them, later they themselves disseminated the results to the community. Some community level activities initiated by the women were evident, though not formally assessed. In most instances, other family members (children, husband and parents) and volunteers also made an effort to get the neighboring households involved. Initially, the volunteers visited the allocated houses once in a fortnight and gradually reduced the visits when the activities were established. The volunteers’ arranged group meetings with the women in the selected households once a month in the first three months, followed by once in every one and a half months.
Distribution of educational materials
Education materials (posters, leaflets and short video clips) were also distributed to community clinic centers, local shops, religious centers, preschools, and schools in the selected GN divisions.
School based intervention to train the
schoolchildren to be change agents
The objective of the school-based intervention was to improve students’ knowledge of health effects of exposure to SHS and the right to smoke free living and to use them as change agents to educate their mothers/women in their households and declare smoke free homes. The schoolchildren in grades 8–10 of six secondary schools in the intervention GN divisions were selected for this purpose. The Public Health Inspectors who received the training as a part of the same intervention delivered two 45 min sessions over two days. The duration of these sessions is consistent with regular school lessons. Teaching methods included active learning activities such as lecture discussions, role-playing and storytelling. All programs were delivered to students in their usual classroom setting, during school hours. In addition, all the students in six schools were invited to participate in a poster competition to promote the message “right to smoke free living”. |
Data collection
Fidelity
Statistical analysis
Results
Participation and completion rate
Fidelity
Completers and non-completers
Baseline characteristics
Intervention group (n = 329) | Control group (n = 309) | Significance | ||
---|---|---|---|---|
Age in years mean (SD) | 40.4 (± 10.5) | 39.9 (± 9.2) | 0.55 | |
Place of residence n(%) | Rural | 316 (96) | 294 (95.1) | χ2 = 0.31,df = 1
p = 0.57 |
Estate | 13 (4.0) | 15 (4.9) | ||
Ethnicity n(%) | Sinhalese | 291 (88.4) | 274 (88.7) | χ2 = 0.56,df = 2
p = 0.75 |
Tamil | 8 (2.4) | 10 (3.2) | ||
Muslim | 30 (9.1) | 25 (8.1) | ||
Education n(%) | No schooling | 19 (5.8) | 16 (5.2) | χ2 = 2.75,df = 3
p = 0.43 |
Primary level (Grade 1–5) | 47 (14.3) | 58 (18.8) | ||
Junior high school | 179 (54.4) | 166 (53.7) | ||
High school or higher | 84 (25.5) | 69 (22.3) | ||
Occupation n(%) | Housewife | 219 (66.6) | 217 (70.2) | χ2 = 0.98,df = 1
p = 0.32 |
Employed | 110 (33.4) | 92 (29.8) | ||
Monthly income SLR n(%) | up to 20,000 | 153 (46.5) | 134 (43.4) | χ2 = 0.63,df = 2
p = 0.73 |
20,001–40,000 | 161 (48.9) | 160 (51.8) | ||
>40,000 | 15 (4.6) | 12 (4.9) |
Exposure to SHS
Outcomes | Intervention group (n = 329) | Control group (n = 309) | Significance | ||
---|---|---|---|---|---|
Pre | Post | Pre | Post | ||
n (%) significance |
n (%) significance | ||||
Exposure to SHS in their households within last 7 days | 62 (19.0) | 30 (9.2) | 53 (17.3) | 47 (15.3) | pre p2 = 0.58 |
post p2 = 0.02 | |||||
p1 < 0.001 | p1 = 0.51 | ||||
Exposure to SHS in their households within last 30 days | 79 (24.3) | 44 (13.6) | 70 (22.9) | 65 (21.6) | pre p2 = 0.67 |
post p2 = 0.008 | |||||
p1 < 0.001 | p1 = 0.70 |
Knowledge and attitudes of women related to SHS exposure in the household
Outcomes | Intervention group (n = 329) | Control group (n = 309) | Significance | ||
---|---|---|---|---|---|
Pre | Post | Pre | Post | ||
Median significance | Median significance | ||||
Knowledge on health risk of exposure to SHS | 9 | 11.0 | 9.0 | 10.0 | Pre p2 = 0.67 |
post p2 < 0.001 | |||||
p1 < 0.001 | p1 < 0.001 | ||||
Attitude on exposure to SHS | 11 | 12.0 | 11.0 | 11.0 | pre p2 = 0.12 |
Post p2 = 0.004 | |||||
p1 < 0.001 | p1 < 0.001 | ||||
Attitudes on right to smoke free living | 5.0 | 5.0 | 5.0 | 5.0 | pre p2 = 0.32 |
post p2 = 0.001 | |||||
p1 < 0.001 | p1 < 0.001 | ||||
Attitudes on women empowerment against SHS | 5 | 8.0 | 5.0 | 6.0 | pre p2 = 0.98 |
post p2 < 0.001 | |||||
p1 < 0.001 | p1 < 0.001 |
Observed evidence of smoking
Exposed to SHS within 7 days | Intervention group (n = 329) | Control group (n = 309) | Significance | ||
---|---|---|---|---|---|
Pre n (%) | Post n (%) | Pre n (%) | Post n (%) | ||
Exposed | |||||
Observed evidence present | 54 (87.1) | 19 (63.3) | 49 (92.5) | 40 (85.1) | Pre p2 = 0.35 Post p2 = 0.03 |
Observed evidence not present | 8 (12.9) | 11 (36.7) | 4 (7.5) | 7 (14.9) | |
p1 = 0.008 | p1 = 0.24 | ||||
Not exposed | |||||
Observed evidence present | 12 (4.5) | 6 (2.0) | 9 (3.6) | 11 (4.2) | Pre p2 = 0.57 Post p2 = 0.13 |
Observed evidence not present | 252 (95.8) | 290 (98.0) | 244 (96.4) | 249 (95.8) | |
p1 = 0.09 | p1 = 0.69 |