THE EFFECTIVENESS OF GROUP THE EFFECTIVENESS OF GROUP COUNSELING MODULE IN SMOKING COUNSELING MODULE IN SMOKING

CESSATION PROGRAM : CESSATION PROGRAM : QUANTITATIVE AND QUALITATIVE QUANTITATIVE AND QUALITATIVE

APPROACHESAPPROACHES

Rohani IsmailRohani Ismail11, Syed Aljunid, Syed Aljunid22, Khalib Abd Latip1,Wan Sharifa Ezat , Khalib Abd Latip1,Wan Sharifa Ezat Wan PutehWan Puteh11

11Department of Community Health, Faculty of MedicineDepartment of Community Health, Faculty of MedicineUniversiti Kebangsaan MalaysiaUniversiti Kebangsaan Malaysia

22United Nations University-International Institute For Global United Nations University-International Institute For Global Health, Kuala Lumpur MalaysiaHealth, Kuala Lumpur Malaysia

3RD MCTC CONFERENCE 8-9 AUGUST 2009

INTRODUCTIONINTRODUCTION• The onset of tobacco use typically occurs during The onset of tobacco use typically occurs during

childhood or adolescence.childhood or adolescence.

• The Third National Health Mobidity Survey in The Third National Health Mobidity Survey in 2006 reported that the national prevalence of 2006 reported that the national prevalence of current smoking increase among adolescents age current smoking increase among adolescents age 13 to 17 years old [13(3.5%), 14 (6.0%), 15 13 to 17 years old [13(3.5%), 14 (6.0%), 15 (8.7%), 16 (12.0%), 17 (15.5%)]. (8.7%), 16 (12.0%), 17 (15.5%)].

• Strong positive correlation between the age of Strong positive correlation between the age of starting experiment with cigarette smoking and starting experiment with cigarette smoking and the probability of becoming a regular smoker the probability of becoming a regular smoker (Conrad et al., 1992) (Conrad et al., 1992)

PROBLEM STATEMENTPROBLEM STATEMENT• Smoking being a health problem especially among the adolescents Smoking being a health problem especially among the adolescents

and its continuation throughout adulthood, thus it is important to and its continuation throughout adulthood, thus it is important to formulate preventive and cessation programs at addressing this formulate preventive and cessation programs at addressing this particular age group.particular age group.

• Intervention via group counseling may proof to be one of the Intervention via group counseling may proof to be one of the effective methods for helping adolescent for quitting smoking.effective methods for helping adolescent for quitting smoking.

• Group counseling is especially suited for adolescents because it gives Group counseling is especially suited for adolescents because it gives them a place to express conflicting feelings, to explore self doubts, them a place to express conflicting feelings, to explore self doubts, and to come to the realization that they share these concerns with and to come to the realization that they share these concerns with their peers (Gerald C, 2000).their peers (Gerald C, 2000).

• Although school counselors are assumed to have sufficient skills in Although school counselors are assumed to have sufficient skills in managing counseling sessions among students, the structured managing counseling sessions among students, the structured method tailored for smoking cessation program is underprovided.method tailored for smoking cessation program is underprovided.

• This present research was design to address the aspects mentioned This present research was design to address the aspects mentioned aboveabove

GENERAL OBJECTIVEGENERAL OBJECTIVE To measure the effectiveness of smoking cessation To measure the effectiveness of smoking cessation program using quantitative and qualitative methodsprogram using quantitative and qualitative methods

Specific Objectives Specific Objectives 1.1. To study the smokers characteristics in intervention To study the smokers characteristics in intervention

and nonintervention group and nonintervention group 2.2. To measure quit rate of smoking before and after To measure quit rate of smoking before and after

the intervention programthe intervention program3. To predict quit smoking among adolescents3. To predict quit smoking among adolescents4. To identify the strengths and weaknesses of the 4. To identify the strengths and weaknesses of the

programprogram

MeasurementsQuantitative • Self report (questionnaire) - Smoking previous 7 days• Cotinine in urine - GCMS (Gass Chromatography Mass

Spectrometry) • Carbon monoxide exhale - Carbon monoxide analyzer

Qualitative• Guidelines questionnaire (in depth interviews)

Operational Definition• Adolescents smoking – respondents 14 years old smoking at

least one day during 30 days prior to the study (GYTS, WHO) confirmed by self reported and carbon monoxide exhaled.

• Intervention group – adolescents received group counseling on smoking cessation by trained counselors for a period of four months

• Non intervention group – did not receive any counseling but the respondents were subjected to the regular smoking cessation activities organized by their respective schools

• Group counseling – a group of adolescents (not more than 10 adolescents) received counseling based on module developed

• Counselor – full time school counselor, qualified in Degree in Counseling and Psychology with one year experience in counseling field.

• Intention to stop smoking – adolescents have intention to stop smoking in stage of contemplation, preparation and action

Contemplation – thinking about quitting Preparation – seriously thinking about quitting Action – seriously thinking and high motivation in quitting.

• Level of addiction – based on Modified Fagerstrom Test for Nicotine Tolerance comprise of six questions

• Quit rate – stop smoking in 7 day point prevalence by self reported (questionnaire), verified by cotinine in urine and carbon monoxide exhaled at 4, 8 and 12 months post baseline.

- cotinine < 99.99ng/ML - carbon monoxide < 6 ppm

• Effectiveness of intervention – increase of quit rate at 4, 8 and 12 months post baseline.

METHODOLOGYMETHODOLOGY• Purposive sampling was conducted to choose Purposive sampling was conducted to choose

Gombak and Hulu Langat districtGombak and Hulu Langat district

• 24 schools randomly selected in two districts. 24 schools randomly selected in two districts.

• All form two students go through a screening All form two students go through a screening process to identify the smoker who had an process to identify the smoker who had an intention to stop smoking.intention to stop smoking.

• The research pass through The research pass through 3 phases3 phases::

MODULE DEVELOPMENT BY RESEARCH TEAM and PRE TESTED

SCREENING PROCESS(smoking at least one day past 30 days an intention to stop at contemplation, preparation and action stage )

(N = 346)

INTERVENTION GROUP(n=158)

NON INTERVENTION GROUP(n = 188)

Measure of quit rate (8 moths post baseline)

Measure of quit rate (4 moths post baseline)

PHASE

1

PHASE

2

PHASE

3

Program evaluation(in depth interview among

counselors)

STUDY FLOW

Measure of quit rate (12 moths post baseline)

Group counseling intervention

Usual practice

Program EvaluationQualitative method• strength and weaknesses of the program• activities implemented in non intervention schools• - in-depth interview - Involved 10 counselors – justified on the

consensus information

• Interviews was recorded on tape and transcribed• The transcripts were manually analyzed - theme and

keywords

SMOKING CESSATION PACKAGE

1 2 3 4 5 6 7 8 9* 10 11 12 13 14 15* 16 17 18 19 20 21 22 23 *24

1st session = Iice breaking (4 h)

2nd session = Brain storming (4 h)

3rd session = Decision making (2 h)

4th session = Decision making (2 h)

5th session = Decision making ( 2 h)

1st ses. 2nd ses. 3rd & 4th ses. 5th ses.

7th ses. 8th ses. 9th

ses.

10th ses.

6th session = Managing withdrawal symptom 1 (4 h) session = Managing withdrawal symptom 2 (2 h)

8th session = Managing daily activities (2 h)

9th session = Reflection Activities (2 h)

10th session = Outdoor activities (3 days 2 nights)

COUNSELLING SESSION

WEEK

1st MODULE = PREPARATION TO STOP SMOKING (1st ,2nd session)

2nd MODULE = DECISION MAKING (3rd ,4th ,5th session)

3rd MODULE = MANAGING WITHDRAWAL SYMPTOM WITHDRAWAL SYMPTOM (6th ,7th session)

4th MODULE = REMAINING CESSATION STATUS ( 8th ,9th ,10th session)

6th ses.

JULY 2005 OCTOBER 2005

RESULTSRESULTS

13

87

MaleFemale

Figure 1 : Respondents distribution by gender (n= 346)

Figure 2 : RespondentsFigure 2 : Respondents distribution by istribution by ethnics ethnics (n= 346)

96

0.9

2.6

0.6

MalayChineseIndianOthers

Figure 3 : Initiation age of Figure 3 : Initiation age of start smokingstart smoking

9 7.1

51.6

18.1

0

10

20

30

40

50

60

<7 to 9years 10 or 11 years 12 or 13 years 14 or 15 years

Figure 4 : Stage of changes quitting Figure 4 : Stage of changes quitting smokingsmoking

40.2

24.9

35

05

1015202530354045

Contemplation Preparation Action

Figure 5 : Number of Figure 5 : Number of cigarettescigarettes

56.135.3

8.4

1 stick2-5 sticks>6 sticks

Figure 6 : Number of smoking Figure 6 : Number of smoking dayday

45.6

36.9

17.4

05

101520253035404550

1-5 days 6-19 days 20-30 days

Table 1 : Baseline characteristic of study Table 1 : Baseline characteristic of study groupgroup

PARAMETERPARAMETER IGIG(n= 158)(n= 158)

NIGNIG(n= 188)(n= 188)

P P valuevalue

MaleMale FemaleFemale

143 (90.5)143 (90.5) 15 ( 9.5)15 ( 9.5)

158 (84.0)158 (84.0) 30 (16.0)30 (16.0)

0.0750.075

MalayMalay ChineseChinese IndiaIndia

153 (96.8)153 (96.8) 2 (1.3)2 (1.3) 3 (1.9)3 (1.9)

179 (95.2)179 (95.2) 3 (1.5)3 (1.5) 6 (3.2)6 (3.2) 0.4250.425

Initiation age of Initiation age of smokingsmoking < 7-9 years< 7-9 years 10-11 years10-11 years 12-13 years12-13 years 14 years14 years

12 (7.6)12 (7.6) 25 (15.8)25 (15.8) 91 (57.6)91 (57.6) 30 (19.0)30 (19.0)

19 (10.2)19 (10.2) 34 (18.2)34 (18.2) 87 (46.5)87 (46.5) 47 (25.1)47 (25.1) 0.2220.222

PARAMETERPARAMETER IGIG(n= 158)(n= 158)

NIGNIG(n= 188)(n= 188)

P P valuvaluee

Number of Number of cigarettescigarettes 1 stick1 stick 2-5 sticks2-5 sticks >6 sticks>6 sticks

80 (50.6)80 (50.6)63 (39.9)63 (39.9)15 ( 9.5)15 ( 9.5)

114 (61.0)114 (61.0) 59 (31.6)59 (31.6) 14 (7.5)14 (7.5) 0.1560.156

Number of days Number of days smokingsmoking 1-5 days1-5 days 6-19 days6-19 days 20-30 days20-30 days

53 (38.1)53 (38.1)55 (39.6)55 (39.6)31 (22.3)31 (22.3)

83 (52.5)83 (52.5)55 (34.6)55 (34.6)21 (13.2)21 (13.2)

0.0270.027

PARAMETERPARAMETER IGIG(n= 158)(n= 158)

NIGNIG(n= 188)(n= 188)

P valueP value

Stage of Stage of changeschanges ContemplationContemplation PreparationPreparation ActionAction

66 (41.8)66 (41.8) 37 (23.4)37 (23.4) 55 (34.8)55 (34.8)

73 (38.8)73 (38.8)49 (26.1)49 (26.1)66 (35.1)66 (35.1)

0.8070.807

Fagerstrom Fagerstrom ScaleScale Less Less addictedaddicted Moderate Moderate addictedaddicted High High addictedaddicted

138 (87.3)138 (87.3) 18 18 (11.4)(11.4) 2 (1.3)2 (1.3)

161 (85.6)161 (85.6) 21 (11.2)21 (11.2) 6 (3.2)6 (3.2)

0.4940.494

Table 4 : Smoking quit rate among intervention and non intervention group

Intervention

(n = 158)

Non intervention(n = 188)

Chi square test

4 months post baseline

71 (44.9) 60 (31.9) 6.19 (0.01)*

8 months post baseline

33 (20.9) 45 (23.9) 0.46 (0.50)

12 months post baseline

29 (18.4) 49 (26.1) 2.92 (0.09)

* P < 0.005

Factors Wald Adjusted odds ratio

95% CI P value

Sex Male Female

7.54 2.67 1.32 – 5.36 0.006*

Received counseling Yes No

6.49 2.00 1.17 – 3.40 0.01*

Intention tostop smokingActionContemplation

8.31 2.36 1.31 – 4.24 0.00*

Parent smoking Yes No

4.31 1.68 1.03 – 2.74 0.04*

Table 5 : Predictors on quit smoking

Strength of the program

i) Improved respondents personality- improved students’ discipline

- improved academic achievement - highly motivated to stop smoking ii) Enhanced cohesiveness between respondents and counselors - maintain good relationship

iii) Positive knowledge delivery on smoking cessation - valuable information on smoking cessation to counselors as well as to respondents iv) Creation of awareness about the harmful effects of smoking habit - posters and movie related to smoking diseases contribute high impact to students v) Being a counselor-friendly module - easy-follow module, informatics and comprehensive. - easy access module for counselor in student assessment

• Weaknesses of the program i) Time constraints - program begin at mid of the year - increase counselor workload at year-end. - students commit with exam and school holiday ii) Lack of commitment from school administrators - counseling during teaching hours was unfavorable

Quantitatively,• The quit rate at four months after intervention was determined higher in

the IG as compared to the NIG. - due to counseling and developing motivation from the intervention

• after 8 and 12 month follow up • relapse among adolescents behavior of smoking. - due to inconsistence monitoring - due to inconsistence monitoring

Qualitatively- Improved personality of respondents, enhanced cohesiveness between respondents and counselors, positive inputs on smoking cessation, creation of awareness about the harmful, effects of smoking habit, being a counselor-friend module

The strength of the module was affected by: Time limitation and commitment from school counselor.

DISCUSSION

ConclusionConclusion• The module is effective in encouraging The module is effective in encouraging

respondents to quit smoking only in the respondents to quit smoking only in the short term. short term.

• Therefore the duration of intervention Therefore the duration of intervention should be extended to ensure the quit rate should be extended to ensure the quit rate among adolescents sustain in the long term.among adolescents sustain in the long term.

• Qualitative study identified more of the strength factors mentioned as compared to the weaknesses of the program

ReferencesReferences• Conrad, K.M., Flay, B. R. & Hill, D. 1992. Why children start Conrad, K.M., Flay, B. R. & Hill, D. 1992. Why children start

smoking cigarette: predictors of onset. smoking cigarette: predictors of onset. Br J AddictionBr J Addiction. . 8787 : 1711- : 1711-1724.1724...

• Hashami Bohari (1998). Keberkesanan Pakej Pendidikan Hashami Bohari (1998). Keberkesanan Pakej Pendidikan Kesihatan untuk Modifikasi Tingkahlaku Merokok. Kesihatan untuk Modifikasi Tingkahlaku Merokok.

• Gerald Corey. 2000. Gerald Corey. 2000. Theory and Practice of Group CounselingTheory and Practice of Group Counseling. 5th . 5th edition. Brooks/Cole Thomson Learning. USAedition. Brooks/Cole Thomson Learning. USA

• Lee Pi Hsia., Wu Der Min, Lai Hsiang Ru, Chu Naing-Feng. 2007. Lee Pi Hsia., Wu Der Min, Lai Hsiang Ru, Chu Naing-Feng. 2007. The impacts of a school wide no smoking strategy and classroom-The impacts of a school wide no smoking strategy and classroom-based smoking prevention curriculum on the smoking behavior of based smoking prevention curriculum on the smoking behavior of junior high school students. junior high school students. Addictive BahaviorAddictive Bahavior 3232. 2099 – 2107. 2099 – 2107

• Nagmeldien Ahmed M. Magzoub, Mohamed Izham Mohamed Nagmeldien Ahmed M. Magzoub, Mohamed Izham Mohamed Ibrahim.2009. Health promotion Initiatives : Smoking Cessation Ibrahim.2009. Health promotion Initiatives : Smoking Cessation Program and Weight Management. Penerbitan USM. Pulau PinangProgram and Weight Management. Penerbitan USM. Pulau Pinang..

• JamesJames D. S dan Joseph R. D. 2003. Tobacco Control for Clinicians D. S dan Joseph R. D. 2003. Tobacco Control for Clinicians Who Treat Adolescents. CA Who Treat Adolescents. CA Cancer Journal ClinCancer Journal Clin 53: 102-123. 53: 102-123.

• O’Connel DL, Alexander HM, Dobson AJ et al. 1981. Cigarette O’Connel DL, Alexander HM, Dobson AJ et al. 1981. Cigarette smoking and drug use in school students 111. Factors associated smoking and drug use in school students 111. Factors associated with smoking. with smoking. Int. J .EpidInt. J .Epid. 110 : 221-231.. 110 : 221-231.

• Global Youth Tobacco Survey Malaysia report. NCDC, MOHGlobal Youth Tobacco Survey Malaysia report. NCDC, MOH• National Health Morbidity Survey 2006. MOHNational Health Morbidity Survey 2006. MOH

AcknowledgementAcknowledgement• Ministry of HealthMinistry of Health• Ministry of EducationMinistry of Education• National Poison CentreNational Poison Centre• Pejabat Pelajaran Daerah Hulu Pejabat Pelajaran Daerah Hulu

LangatLangat• Pejabat Pelajaran Derah GombakPejabat Pelajaran Derah Gombak• MCTCMCTC

Research TeamResearch Team•Prof. Dr Syed Mohamed Prof. Dr Syed Mohamed AljunidAljunid• P.M Dr Khalib Abd latipP.M Dr Khalib Abd latip•Dr. Sharifah EzatDr. Sharifah Ezat•En. Razak LajisEn. Razak Lajis•Dr Maizurah OmarDr Maizurah Omar•P.M Dr. Foong KinP.M Dr. Foong Kin•Prof Dr. Hashami Prof Dr. Hashami BohariBohari•Dr. Nor Saleha Ibrahim Dr. Nor Saleha Ibrahim Tamin Tamin •Dr. Nik Rubiah binti Nik Dr. Nik Rubiah binti Nik Abdul Rasid Abdul Rasid •Pn Ivy Ho Siew YoonPn Ivy Ho Siew Yoon

•Pn SalamatussaadahPn Salamatussaadah•En. Ahmad FadliEn. Ahmad Fadli•En Ahamad FuadEn Ahamad Fuad•Cik Azlina AdnanCik Azlina Adnan•En David a/l SamanasuEn David a/l Samanasu•Dr Taniza TohaDr Taniza Toha•Dr. Zabani DarusDr. Zabani Darus•Dr Aminah KassimDr Aminah Kassim•En Lim Beng Kung En Lim Beng Kung •Cik Salina binti Nen Cik Salina binti Nen •Cik Normah Che DinCik Normah Che Din•Rohani Ismail Rohani Ismail

ACTIVITIES AT SCHOOLACTIVITIES AT SCHOOL

THANK THANK YOUYOU