the effect of peer-to-peer health education on … · rekabentuk kuasi-eksperimen dijalankan dengan...
TRANSCRIPT
THE EFFECT OF PEER-TO-PEER HEALTH EDUCATION ON THE
PERCEPTION OF THE SMOKING OUTCOMES AMONG
. ADOLESCENTS IN KUCHING, SARAWAK, 2007.
JEFFERY ANAK STEPHEN
A thesis submitted in fulfillment of the requirements for the Masters of Public
Health (Health Promotion).
Faculty of Medicine and Health Sciences
UNIVERSITI MALAYSIA SARAWAK
2009
DEDICATION
To my wife, Kuang, and my two little princesses, Samantha Grace and Eleora Hanna, for their
loving patience and limitless support.
iii
ACKNOWLEGDEMENTS
Warm thanks to many individuals, both directly and indirectly, influenced me and helped
me to complete this project. Of course, in particular I would like to thank my supervisor,
Professor Madya Dr. Siti Raudzah Ghazali for her guidance, patience, advice and encouragement
throughout the project.
Many, many thanks to Tan Sri Datu Dr. Mohd. Taha b. Arif, Professor Dr. Mohd. Syafiq
b. Abdullah, Professor Dr. Mohd. Raili b. Suhaili and Professor Madya Dr. Kamaruddin b. Bakar
for their positive comments and guidance; and to Professor Dr. Nooriah bt. Mohd Salleh and
Mdm. Cheah Whye Lian for their assistance in statistical analysis.
Many thanks to Dr. Haji Jamail b. Haji Muhi who is the Kuching Division Health
Officer, for allowing me to co-operate with the Unit Promosi Kesihatan in completing my
project; and to Mdm Pises Busu and Mr. Cairol b. Baseri for helping me with the data collection.
I also want to acknowledge the school principals, teachers and students of SMK Padawan, SMK
Lundu, Kpg. Keranji and Kpg. Haji Baki for their involvement in the project.
iv
TABLE OF CONTENTS
DECLARATION
DEDICATION
ACKNOWLEDGEMENTS
TABLE OF CONTENTS
APPENDIX
LIST OF TABLES
LIST OF FIGURES
ABBREVIATIONS
ABSTRACT
AB STRAK
CHAPTER 1. INTRODUCTION AND LITERATURE REVIEW
1.1. Introduction.
1.1.1. Purpose of the study.
1.1.2. Background of the study area.
1.1.3. Significance of the study.
1.2. Literature review.
1.2.1. Introduction.
1.2.2. Adolescent and the theory of perception. 1.2.3. Adolescent and perception of smoking outcomes.
1.2.4. Defining "peer" and "peer-to-peer health education".
1.2.5. The impact of peer-to-peer health education on adolescents in relation to smoking. 1.2.6. Conclusion.
1.3. Statement of the problem.
1.4. Research Objectives.
1.4.1. General Objectives.
1.4.2. Specific Objectives.
1.5. Research Hypotheses.
11
111
iv
V
viii ix
X
xi
xii
xiii
1
2
2
3
5
5
6
9
12
14
17
19
20
20
20
20
V
CHAPTER 2. MATERIALS AND METHODOLOGY
2.1. Methodology.
2.1.1. Research design.
2.1.2. Sample population.
2.1.3. Sampling method.
2.1.3.1. Inclusion and exclusion criteria.
2.1.4. Sample size calculation.
2.1.5. Procedures and data collection. 2.1.5.1. Ethical Approval.
2.1.5.2. Description of the implementation of the programme.
2.1.5.3. Description of the intervention programme.
2.1.5.4. Assessing the intervention programme. 2.2. Materials.
2.2.1. Questionnaire.
2.2.1.1. Section A: Demography.
2.2.1.2. Section B: Smoking Outcomes Perception Scale (SOPS).
2.2.2. Pilot study.
2.3. Data entry and analysis. 2.4. Operational definitions.
CHAPTER 3. RESULTS
3.0. Introduction.
3.1. Analysis of SOPS.
3.2. Descriptive analysis of the characteristic profiles of the participants. 3.2.1. Age.
3.2.2. Gender.
3.2.3. Ethnicity and Religion.
3.2.4. Other characteristics.
3.2.5. Preliminary data analysis
21
21
22
23
23
23
24
24
25
25
27
29
29
29
29
31
32
33
34
34
38
40
40
40
41
43
vi
3.3. Evaluation analysis of peer-to-peer health education programme with respect to the research
questions and hypotheses.
3.3.1. Research Question #1: Do adolescents change their perception of smoking outcomes
after attending peer-to-peer health education?
3.3.2. Research Question #2: Do male and female adolescents differ in their perception of
smoking outcomes after attending peer-to-peer health education? 3.3.3. Research Question #3: Do Malay and Dayak adolescents differ in their perception of
smoking outcomes after attending peer-to-peer health education?
45
45
48
52
CHAPTER 4. DISCUSSION, LIMITATIONS AND CONCLUSION
4.1. Discussion. 56
4.2. Limitations. 62
4.3. Conclusion. 67
CHAPTER 5. IMPLICATIONS AND RECOMMENDATIONS
5.1. Implications. 68
5.2. Recommendations. 70
BIBLOGRAPHY 72
vii
APPENDIX
APPENDIX A: Approval letter from the Faculty's Ethic Committee 99
APPENDIX B: Approval letter from the Divisional Health Officer of Kuching Division 101
APPENDIX C: Questionnaire 103
viii
LIST OF TABLES
Table 3.1 Factor analysis of the smoking outcomes perception with principle component
extraction, Varimax rotation and eigenvalue of 2, conducted among twenty local
adolescents. 36
Table 3.2 Cronbach's alpha and test-retest coefficients for the smoking outcome perception
scale conducted among twenty local adolescents. 37
Table 3.3 Number (percentages) of participants who were attended the workshop and eligible for the study. 38
Table 3.4 Characteristic profiles of the participants between the intervention and the control
groups. 42
Table 3.5 The median scores before and after the intervention sessions and statistical results for
both groups. 47
Table 3.6 The median scores before and after the intervention sessions, and statistical results for
male and female adolescents in the intervention group. 50
Table 3.7 The median scores before and after the intervention sessions, and statistical results for
male and female adolescents in the control group. 51
Table 3.8 The median scores before and after the intervention sessions, and statistical results for
the Malay and the Dayak adolescents in the intervention group. 54
Table 3.9 The median scores before and after the intervention sessions, and statistical results for
the Malay and the Dayak adolescents in the control group. 55
ix
LIST OF FIGURES
Fig 1.1 Conceptual framework related between perception, smoking outcomes and health
education.
Fig 2.1 Map of Kuching division and the four locations that involved in the current study.
8
22
Fig 2.2 Flowchart of Research Methodology. 28
X
ABBREVIATIONS
CDC Centers for Disease Control and Prevention
C. I. Confidence Interval
GMOS General Medical Outcomes Perception Subscale
IQR Inter-quartile range
MOH Ministry of Health, Malaysia
PROSTAR Program Sihat Tanpa AIDS untuk Remaja
PWOS Physical Well-being Outcomes Perception Subscale
SOPS Smoking Outcome Perception Scale
UK United Kingdom
UNAIDS Joint United Nations Programme on HIV/AIDS
USDHHS U. S. Department of Health and Human Services
WPRO Western Pacific Region Office
WHO World Health Organization
xz chi-squared test
d. f. degree of freedom
M Mean
Mdn Median
n Sample size
p Probability value
r Effect size
SD Standard deviation
T Wilcoxon Signed Rank T test
U Mann-Whitney U test
X1
ABSTRACT
THE EFFECT OF PEER-TO-PEER HEALTH EDUCATION ON THE PERCEPTION OF THE SMOKING OUTCOMES AMONG ADOLESCENTS IN KUCHING, SARAWAK, 2007.
Jeffery anak Stephen
i The main objective of the study was to examine whether the peer-to-peer health education was
effective in changing the perception of the smoking outcomes among local adolescents in
Kuching, Sarawak This study adopted a quasi-experimental design with 55 participants in
intervention group and 41 participants in the control group. The intervention group was subjected
to one session of peer-to-peer education. Baseline data for smoking outcomes was collected
before the intervention and the data was collected one day after the intervention by using
Smoking Outcome Perception Scale (SOPS)'Nonparametric analyses of the scores showed that
the peer-to-peer health education significantly changed the smoking outcomes perception among
the participants in the intervention group (Wilcoxon Signed Rank test, p< . 05) with significant
change in the scale scores observed among the males (Wilcoxon Signed Rank test, p< . 05
participants of the Dayak ethnicity showed significant change in the smoking outcomes
perceptions after they attended the peer-to-peer health education session (Wilcoxon Signed Rank
test, p< . 05). Neither the females nor those of the Malay ethnicity showed any significant change
in in the smoking outcomes perception (Wilcoxon Signed Rank test, p> . 05). These modest
findings lend credence that peer-to-peer health education is effective in changing the smoking
outcomes perception among local adolescents with diverse cultural background.; %
xii
ABSTRAK
KESAN PENDIDIKAN KESIHATAN OLEH RAKAN KEPADA RAKAN SEBAYA KE ATAS PERSEPSI KESAN-KESAN MEROKOK DI KALANGAN REMAJA DI
KUCHING, SARAWAK, 2007.
Jeffery anak Stephen
Objektif utama kajian ini ialah untuk mengkaji sama ada pendidikan kesihatan oleh rakan kepada
rakan sebaya dapat mengubah persepsi kesan-kesan merokok di kalangan remaja tempatan di
Kuching, Sarawak. Rekabentuk kuasi-eksperimen dijalankan dengan melibatkan 55 orang
peserta di dalam kumpulan rawatan dan 41 orang peserta di dalam kumpulan kawalan. Satu sesi
pendidikan kesihatan oleh rakan kepada rakan sebaya telah dijalankan ke atas kumplan rawatan.
Data dasar untuk persepsi kesan-kesan merokok yang mana diukur oleh skala persepsi kesan-
kesan merokok telah diambil sebelum sesi intervensi dan dengan menggunakan skala yang sama,
data pasca-intervensi diambil sehari selepas sesi intervensi. Ujian tak berparameter untuk skor-
skor telah menunjukkan pendidikan kesihatan oleh rakan kepada rakan sebaya secara
signifikannya telah mengubah persepsi kesan-kesan merokok di kalangan peserta di dalam
kumpulan intervensi (Ujian pangkat bertanda Wilcoxon, p< . 05) dengan signifikan perubahan
skor di kalangan peserta lelaki (Ujian pangkat bertanda Wilcoxon, p< . 05). Peserta berketurunan
Dayak juga telah menunjukkan perubahan signifikan di dalam persepsi kesan-kesan merokok
selepas mereka menghadiri pendidikan kesihatan oleh rakan kepada rakan sebaya (Ujian pangkat
bertanda Wilcoxon, p< . 05). Tiada peserta perempuan mahupun peserta berketurunan Melayu
menunjukkan perubahan signifikan di dalam persepsi kesan-kesan merokok (Ujian pangkat
bertanda Wilcoxon, p> . 05). Hasil keputusan ini telah membuktikan kebenaran bahawa
pendidikan kesihatan oleh rakan kepada rakan sebaya adalah efektif dalam mengubah persepsi
kesan-kesan merokok di kalangan remaja tempatan yang mempunyai latar-belakang pelbagai
budaya.
X111
CHAPTER 1
INTRODUCTION AND LITERATURE REVIEW
1.1. Introduction
According to the recent statistics, smoking accounts for one out of every five
deaths in Malaysia and these numbers are expected to triple over the next three decades
from 10,000 in 1998 to 30,000 by the year 2030 (Ministry Of Health Malaysia [MOH],
2003). About 50 teenagers below the age of 18 start smoking everyday (Western Pacific
Region Office [WPRO], 2002) and usually they start by experimenting it first (Jarvis,
2004; Klein, 2006). Several studies showed that the average age of start smoking is
around 13 to 15 years old (Maziak & Mzayek, 2000; Hammond, 2000). In reaction to the
alarming rates of smoking, increases in anti-smoking literature and campaigns have
emerged to educate the public, primarily targeting the adolescents about the severe
dangers of cigarette smoking. Schools have been suggested to be a platform for health
promotion programmes for the students because this is where the students are easily
accessible (Centers for Disease Control and Prevention [CDC], 1994; CDC, 1999;
Bandura, 2004). Hence, many smoking prevention programs utilizing peer-to-peer health
education approach have been conducted in schools and have been proven effective
(Prince, 1995; Mellanby, Rees & Tripp, 2000; Valente, Hoffman, Ritt-Olson, Lichtman
& Johnson, 2003; Hwang, Yeagley & Petosa, 2004). The application of peer-to-peer
health education approach in a variety of cultural settings such as in Kuching Sarawak,
warranted further research to look into its effectiveness (Paavola, Vartiainen & Puska,
I
2001; Cuijpers, 2002; Scarinci, Robinson, Alfano, Zbikowski & Kiesges, 2002; Ma,
Fang, Tan, Feeley & Thomas, 2003).
1.1.1 Purpose of the study
The purpose of the study was to examine whether the peer-to-peer health
education was effective in changing the perception of smoking outcomes among
adolescents in Kuching, Sarawak. The changes in the perception were measured using
Smoking Outcome Perception Scale (SOPS) before and after the intervention.
1.1.2 Background of the study area
The current study was carried out in Kuching division which consists of three
main subdivisions namely Kuching, Bau and Lundu. There are many ethnic groups in
Kuching division. The population comprises Chinese 35%, followed by Malay 34%,
Dayak 27% and others 4% (Sarawak Population Statistic, 2004).
It is estimated that adolescents in Sarawak consist of 19% of the total population
(Sarawak Population Statistic, 2004). The Dayak (consist of Than and Bidayuh ethnic
groups) form the largest adolescent population with 39%, followed by the Malay 24%,
Chinese 23%, and others 13%.
2
1.1.3. Significance of the study
Smoking is no longer confined to adults. Among young teens (aged 13 to 15),
about one in five smoke worldwide (WPRO, 2002). Between 80,000 and 100,000
children worldwide start smoking every day - roughly half of whom live in Asia (WPRO,
2002). Most smokers acquire the habit before the age of 20 (CDC, 2005). In Malaysia, it
has been estimated that smoking prevalence among teenage boys aged 12-18 years was
30% while smoking among girls has doubled from 4.8% in 1996 to 8% in 1999
(Malaysia's Health, 2002). A local survey carried out in Selangor in 1993 showed that
about 16% of the adolescents aged 13-19 years old were smokers (A. Jalal, et al., 1995).
A cross-sectional study in Negeri Sembilan in 2001 revealed about 14% of secondary
school students were smokers (Lee, Paul, Kam & Jagmohni, 2005). The prevalence of
smoking among the male students was higher (26.6%) compared to the female students
(3.1%) (Lee, et al., 2005). In another separate study, almost one third of all students
surveyed have ever smoked cigarettes and about 20% of them were current smokers, with
boys outnumbering the girls (Krishnan, 2003).
The Ministry of Social Development and Urbanization of Sarawak (2005)
conducted a study on tobacco usage among adolescents in Sarawak. Results showed that
the prevalence of smoking among the Sarawakian adolescents was 36.5% with high
percentages of male smokers, 30.9% compared to the female smokers, 5.6%. This finding
is consistent with the earlier documented reports (Malaysia's Health, 2002; Krishnan,
2003). The mean age of start smoking among the Sarawakian adolescents was 13 years
old which was consistent with other findings (Francoa, et al., 2004; Rius, Fernandez,
Schiaffino & Rodriguez-Artalejo, 2004). Based on ethnicity, the Orang Ulu ethnic group
3
has the highest smoking prevalence (47.2%) followed by the Ibans (40.7%), Melanau
(39.9%), Bidayuh (39%), Malays (37.1%) and Chinese (23.8%) (Ministry of Social
Development and Urbanization of Sarawak, 2005).
The above statistics showed the magnitude of smoking among adolescents in
Malaysia especially in Sarawak which signify the need to identify effective health
promotion interventions. Previous studies have demonstrated the effectiveness of health
education (e. g. Hanewinkel & Aßhauer, 2004; Campbell, et al., 2008). However, little is
known about the effect of peer-to-peer health education on the perception of smoking
outcomes among local adolescents in Kuching. If the predictors of smoking uptake are
different across gender (Brown, Teufel, Birch, Izenberg & Lyness, 2006) and ethnic
groups (Robinson, Kiesges, Zbikowski & Glaser, 1997), then it would be expected that
response to the intervention would also vary. By examining the effect of peer-to-peer
health education, it provides some information to the health personnel in developing and
implementing an effective smoking prevention programme targeted for the local
adolescents.
4
1.2. Literature Review
1.2.1. Introduction
Approximately one in every five people in the world is an adolescent (United
Nations Children's Fund, 2000; Gubhaju, 2002). Adolescent is defined as a person
between 10 and 19 years of age (World Health Organization [WHO], 1998). Despite
being thought to be healthy (WHO, 1998), many of them die prematurely because they
decided to smoke cigarettes (CDC, 2006).
Cigarette smoking almost exclusively starts during adolescence (U. S. Department
of Health and Human Services [USDHHS], 1994; World Bank, 1999) and progression to
become established smokers increases over time as the adolescents progress into
adulthood (Orlando, Tucker, Ellickson & Klein, 2004). Smoking prevention is seen as an
important way of reducing smoking incidence rates among adolescents (Tennesen, 2002).
It is because most adolescents are unaware of the possible health outcomes to which they
are exposed to (Slovic, 1998).
The following reviews focus on: a) adolescent and the theory of perception; b)
adolescent and perception of smoking outcomes; c) defining "peer" and "peer-to-peer
health education"; and d) the impact of peer-to-peer health education on adolescents in
relation to smoking.
5
1.2.2. Adolescent and the theory of perception.
The word `perceive' is derives from the Latin word `percipere': `per' meaning
`thoroughly' and `capere' meaning `to take' (Meri am-Webster's Collegiate Dictionary,
1993; p. 861). Perception has been conceptualized by cognitivists as a process during
which knowledge or awareness is obtained, it has to undergo the processes of selection,
organization and modifications by the brain of specific input from different sensory
organs (Kail & Wicks-Nelson, 1993). These inputs from the sensory organs include see,
hear, smell, taste and touch. Sensations, in this context, generated by the stimuli have
become immediate and basic experiences (Matlin & Foley, 1992). Stimuli can be
observable or unobservable (Combs, Richards & Richards, 1976 as cited in Bunting,
1988).
Perception functions are seen as a logical inference and a rational between the
sensory input of a stimulus and the conclusion that the brain interpreted (Richeimer,
2006). These functions are also referred to the judgement process (Loewenstein, Weber,
Hsee & Welch, 2001). Ultimately, perception gives rise to belief, whether it is true or
false about the surrounding environment (Yolton, 1962). In this context of study,
inaccurate judgements about smoking outcomes can hurt people. So can inaccurate
beliefs about those judgements. If people's understanding is overestimated, then they
may face impossibly hard choices (e. g. unfamiliar ways to stop smoking, without
adequate information). If people's understanding is underestimated, then they may be
needlessly denied the right to choose.
The concept of perception plays a vital role during adolescence. Adolescence is a
transition stage from childhood to adulthood (Erikson, 1950). The adolescents perceive
6
themselves as who they are as a result of his or her socialization-past (Wright, 1977).
They need to use judgement processes (perception functions) which include integration,
evaluation and re-evaluation of all past childhood experiences and choose those that are
appropriate to become what is known as an ego identity (Erikson, 1950 & 1985). It
coincides with the concept of perception where a person will use selection in choosing
events that need to be emphasized and eventually become part of the knowledge
(Bunting, 1998). Past experiences are seen as stimuli which undergo the process of
rational and logical inference in arriving to the conclusion or beliefs.
The relationship between perception and smoking outcomes can be illustrated in a
simple linear model (see Fig. 1.1). The inputs or stimuli can be interpreted as seeing
friends or family members smoking, hearing the benefits and/or harmful effects of
smoking, taste of smoking, smelling the cigarette smoke and touching the cigarette.
These stimuli become immediate events and experiences to the individual. These inputs
then undergo a process of rational and logical inference (the perception functions) to
come to some conclusions or beliefs towards the cigarette smoking whether it is good or
bad. It is during the process of logical inference the information about the harmful effects
(short-term and long-term) of smoking can be emphasized and imbedded through health
education.
7
Figure 1.1.
Conceptual framework between perception, smoking outcomes and health education.
STIMULUS See friends/parents smoking
Hear about benefits/harmful effects of smoking Taste of cigarette
Smell of cigarette smoke Touch of cigarette
Immediate events and experiences
Perception
1 Beliefs
(smoking outcomes)
4
Health Education
Short-term and long-term
health hazards due to smoking
8
1.2.3. Adolescent and perception of smoking outcomes.
Perceived outcomes play an important role in many models of substance use
(Hine, Summers, Tilleczek & Lewko, 1997; Petraitis, Flay & Miller, 1995; Carvajal,
Hanson, Downing, Coyle & Pederson, 2004; Wahl, Turner, Mermelstein & Flay, 2005)
and have been associated with smoking in adolescents (Anderson, Pollak & Wetter,
2002). Bandura (2004) defined the perceived outcomes as "about the expected costs and
benefits for different health habits" (p. 144). In addition, the values placed on those
outcomes may affect the health behaviour (Bandura, 2004).
Perception of smoking outcomes are influenced by two types of cognitive
judgments: that is judgment about the probability of smoking outcomes and judgment
about the desirability of these outcomes (Hine, Tilleczek, Lewko, McKenzie-Richer &
Perreault, 2005). If the outcome seems positive or beneficial to the individual, he or she
may then intend to or actually participate in a particular behaviour. The opposite can also
be stated if the behaviour is thought to be negative or non-beneficial.
The relationship between perception and unhealthy risk-taking behaviours among
adolescents such as smoking, drug use, unprotected sex, alcohol and unsafe driving has
been widely studied. For example, in a comparative study by Cohn, Macfarlane, Yanez &
Imai (1995), adolescents aged between 13 to 18 years perceive such behaviours like
cigarette smoking, drink alcohol, sniff glue, not using seat belts and use of cocaine were
less harmful to them whether they take it experimentally, occasionally or frequently
compared to their parents' perceptions. These differences are probably due to the fact that
adolescents and adults might differ in identifying possible consequences of an option
chosen and place different values of possible consequences with respect to either positive
9
or negative consequences (Furby & Beyth-Marom, 1992). Moreover, there is
considerable evidence of adults seeing themselves as less at risk than others (Quadrel,
Fischhoff, & Davis, 1993).
Smoking outcomes perception in adolescents has been associated with smoking in
the future because they believed that they are invulnerable (Quadrel et al., 1993; Slovic,
1998; Spijkerman, Van Den Eijnden & Engels, 2007). In a cross-sectional study by
Halpern-Felsher, Biehl, Kropp and Rubinstein (2004), adolescents who smoked cigarette
and intend to smoke in the future perceive smoking-related risks to be less likely to occur.
Moreover, they believed that smoking-related benefits are more likely to occur. In
contrast, those non-smoker adolescents with no intention to smoke perceived otherwise.
Studies have demonstrated that the smokers are less likely to be concerned with
the health outcomes/consequences compared to the non-smokers (Mittelmark, et al.,
1987; Weinstein, 1999; Hine et al., 2005). Adolescent smokers perceived that smoking-
related risks were less likely to occur. They also perceived smoking-related benefits as
being more likely to occur (Halpern-Felsher, et al. 2004). Therefore, adolescents who
perceived that smoking has social benefits or serve functional values to them are more
likely to smoke (Epstein, Griffin & Botvin, 2000). In Lundborg and Lindgren study
(2004), there were differentials in risk perceptions in relation to smoking outcomes
among adolescents. However, their study did not discuss further the differences between
the genders and ethnic groups. They also did not suggest any intervention programme to
change the incorrect perceptions. These are the gaps in knowledge that the current study
attempt to answer in relation to local adolescents.
10
Studies have demonstrated that perception on smoking outcomes have been
greatly influenced by two factors that is, gender and ethnicity (Finucane, Slovic, Mertz,
Flynn & Satterfield, 2000; Brown, Teufel, Birch, Izenberg, & Lyness, 2006). For
example, in a cross-sectional study conducted by Ma and colleagues (2003), males were
less likely to perceive risk outcome towards tobacco usage compared to females. The
gender difference is greatly influence by the ethnicity itself and this could be related to
differences of beliefs about gender roles (Kaholokula, Braun, Kana'iaupuni, Grandinetti
& Chang, 2006), the social acceptance of smoking by others of their own ethnic group
(Bush, White, Kai, Rankin & Bhopal, 2003), influence by peer groups (Mermelstein &
The Tobacco Control Network Writing Group, 1999; Kobus, 2003), and family members
(Shakib, et al., 2003). However, these studies have not addressed the needs of the peer-to-
peer health education programme as part of its health promotion strategy in changing
perception on smoking outcomes.
Although Dalton and colleagues (1999) argued that teaching the negative
consequences of cigarette smoking is less likely to change the adolescents' intent to
smoke, health education based on perception of smoking outcomes is still relevant to be
used as part of health promotion activity in efforts to prevent smoking behavior (CDC,
1994). By providing correct information on the health consequences due to smoking, the
adolescents develop some degree of "skills and efficacy beliefs that enable them to
manage the emotional and social pressures to adopt detrimental health habits" (Bandura,
2004, p. 158). Epstein and colleagues (2000) also support that the prevention efforts
should focus on any means of affecting the perception of smoking outcomes.
11
1.2.4. Defining "peer" and "peer-to-peer health education".
Smoking incidence among adolescents is greatly influenced by peers (USDHHS,
1994; Simons-Morton, Haynie, Crump, Eitel, & Saylor, 2001; Unger, et al., 2002; Kobus,
2003; Arnett, 2007). Being pressured by peers who smoke (Ennett & Bauman, 1993;
Denscombe, 2001) and having peers who are involved in high health-risk behaviours
(Lerner & Galambos, 1998; Prinstein, Boergers & Spirito, 2001) are among many factors
to explain the findings. Peer influence also can be seen as a protective factor to such
health-risk behaviours like cigarette smoking (Maxwell, 2002), which is the basis of the
theoretical concept for the peer-to-peer education programme (Campbell, et al., 2008).
The term `peer' relates to one of equal status with another or that an individual
belongs to the same societal group especially based on age, grade or status (Joint United
Nations Programme on HIV/AIDS [UNAIDS], 1999; Stephenson, et al., 2004). Shiner
(1999) described the term `peer' as close friends, habitual associates or relative strangers
who happen to be involved in the same activity in the same setting.
The peer also reflects either a true peer or near peer (McDonald, Grove & Youth
Advisory Forum Members, 2001). A true peer is a person who is considered a member of
a particular group, both by themselves and by other group members (Larkin, 1998). For
example in Larkin's (1998) study, injecting drug users were recruited and trained to
educate and influence their drug and sex network members about HIV-related
behaviours. A near peer is similar but differs in certain circumstances, for example they
may be a few years older. For example in a study conducted by Sheehan, Dicara,
LeBailly and Christoffel (1999), adolescents between ages 14 and 21 years became peer
12