A Health Promotion Initiative for Smoking Cessation

Many health promotion initiatives had been undertaken everywhere. However, the most important is that such initiatives should establish certain aspects of characteristics based on best practice in order to be described as successful. This means that the initiative must be consistent with health promotion values, theories, evidence and understating of the environment (Kahan & Goodstadt 2005). Although the definition of health promotion practice is broadly accepted, it is not fixed to any rigorously defined discipline, and is said to be practised by individuals in diverse organizations, trained in a multiplicity of disciplines (Boutilier et al. 2000). Generally speaking, health promotion initiatives emphasize elements of empowerment, participation, multidisciplinary collaboration, capacity building, equity and sustainable development (Judd et al. 2001). The Ottawa Charter is considered to be the backbone of any health promotion practice and it is acting as the wheel that guides all health professionals into an ideal and best practice of health promotion related issues. In addition, the best practice is provided through effective planning and evaluation. A working guide to help in successfully achieving the goal is by an approach focusing on the following points: identifying the issue, gaining support and forming a working group, conducting a needs assessment and get to knowing your community, developing an action plan, encouraging participation, communicating with the public through the media, implementing change, monitoring, evaluation and adjustments (NLHHP 2003).

In this assay, I will critically review a health promotion initiative by comparing the characteristics of this initiative against the principles of best practice.

The initiative example: (Attention: the abstract is attached at the end of the assignment).

Secker-Walker, Roger H ; Flynn, Brian S. ; Solomon, Laura J. ; Skelly, Joan M. ; Dorwaldt, Anne L.; Ashikaga, Takamaru (2000) Helping Women Quit Smoking: Results of a Community Intervention Program, American Public Health Association, Inc. Volume 90(6), June 2000, pp 940-946.

Smoking lends to health promotion solution:

Smoking is a challenging health problem world-wide and it is considered to be the second major cause of death. It is currently responsible for the death of one in ten adults (WHO 2005). It is clear that smoking cessation is a priority for preventing many diseases and reducing their burden. There is a real need to expand the implementation of strategies to reduce tobacco use such as increasing the cost of cigarettes and implementing comprehensive tobacco-use–prevention and cessation programs. (CDC 2003). Consequently, promoting smoking cessation can have a great impact in reducing the burden of diseases and improving the population health (Ezzati & Lopez 2003). However, the health promotion is not just the responsibility of the health sector, but goes beyond healthy life styles to well being (WHO 2005). As a result, a lot of efforts at different levels are needed in order to control smoking. This could be achieved well only through proper health promotion intervention. Moreover, the health promotion is defined as a set of activities designed to achieve optimal health for all by monitoring and enhancing the heath of everyone and facilitating individual control over the determinants of health (Kahan & Goodstadt 2005). The definition itself sounds a logical solution for the high smoking prevalence among women. This is because of that in order to solve such problem, the women themselves should be actively involved and the community should be empowered. In addition, the physical and social supportive environment should be ensured in order to maintain smoking cessation. This is only ensured through a health promotion initiative.

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The best way to reduce the prevalence of smoking may be to use community-wide programs because smoking behavior is determined by social context. A community approach will remain an important part of health promotion activities (Secker-Walker et al. 2002). It has been proved that health promotion initiative will encourage smoking cessation and could prevent substantial numbers of deaths in the UK (Lewis et al. 2005).

Needs assessment and its accountability for population wishes:

It is crucial, first of all, to identify the issue through the need assessment. This is done by collecting the necessary information that specifies the needs that are considered as priority by the community. This provides an opportunity for the community to become involved in the planning from the beginning (Territory Health Services 2005). The health needs are defined as those states, conditions or factors in the community that, if absent, will prevent people from achieving complete physical, mental and social health (Ritchie et al. 2004). In this project, the need assessment is not well conducted and the different needs were not well assessed. It is not mentioned in this article whether the community profile was analyzed or not. However, the project investigators sat with local people, conducted interviews with key informants and shared information with them. Nevertheless, the following needs could be figured out:

The decline in smoking prevalence among United States women was lagging behind that of men. This necessities the need of research on strategies to accomplish smoking cessation among women.

There is real women’s needs for social support while quitting In addition, their need for assistance with coping with negative affect in the absence of smoking, and their concerns about weight gain following quitting.

Cigarette smoking is a risk factor for cardiovascular diseases. The smoking is a major health problem that can cause death. Many community based programs have been conducted to reduce cardiovascular risk factors, including cigarette smoking. Some of these programs showed the intervention effects on smoking behavior are effective.

After analyzing this article, it is obvious that the need assessment indicates that smoking reduction among women is a priority public health in United States. This is a normative need. The best practice of health promotion emphasizing the sharing of need assessment with local people in order to improve the chance of success of any intervention. In this way, the success is ensured because sharing the results of the needs assessment will raise community awareness about the issues and possible underlying causes, stimulate discussion about ways to address the issues and get the community more involved in planning and decision-making (Territory Health Services 2005). There is clear information in the article that the community members were involved in the planning and implementation of the intervention throughout the five years period. On the other hand, it is not mentioned clearly how they assess the felt needs (i.e. whether the community groups say what they want, or address the problems that they think are important (Territory Health Services 2005)). Nevertheless, the participatory community organization was used to plan and provide widespread support to women smokers as they tried to change their smoking behavior. The comparative and expressed needs were not assessed.

Goals and objectives of the initiative:

It is essential after the needs assessment is over, to set up appropriate goals and objectives. The first step in critical analysis of goal and objectives is whether these had been stated clearly. The goal of this intervention was to reduce the prevalence of cigarette smoking among women aged 18 to 64 years old in Vermont and New Hampshire. This goal is specific, measurable, achievable and includes the nature of change expected. It will be more comprehensive if it was mentioned that it was limited to five years, which is the duration of the project and to specify the amount of smoking prevalence reduction in order to know exactly what intervention success means. However, this goal does identify the broad long term changed that was expected to be achieved ultimately (Hawe et al. 1990).

The objective is not mentioned in this article. Instead they mentioned the sub-objectives. However, by analyzing the article I feel the objective should closely serve the goal. This means that achieving reduction in the smoking prevalence through a positive change in the women smoking behavior. As a result, the objective should be stated as to increase the number of serious quit attempts among women aged 18 to 64 years old in Vermont and New Hampshire by 20% for example. So the objectives will be also specific, measurable, achievable, includes the nature of change expected and time limited (SACHRU 2005).

The sub-objectives were clearly mentioned. These were to increase motivation and intention to quit smoking and confidence in “staying quit” despite weight gain and negative affect, to increase awareness of cessation activities and to strengthen perceived norms and available support to help women quit smoking. It is known that a sub-objective should happen before the objective in the pathway and it might create a change in favour of the objective (Hawe et al. 1990). Keeping this in mind, there is a clear description task of these sub-objectives and they closely serve the objective by taking in account how to overcome women’s negative feeling affect and thus create a change in the behavior. On the contrary, they were not time limited and some of them seems be difficult to be measured like increase confidence in “staying quit” despite weight gain and negative affect and also perceptions of norms.

It is essential for any good health promotion planning to focus on underlying causes and factors that could possibly contribute or lead to the problem (Kahan & Goodstadt 2005). Therefore, development of clear and organized goal and objectives based on a critical analysis of the problem in terms of contributing and risk factors is essential (Territory Health Services 2005). It is not mentioned clearly in this article about the underlying causes of or contributing factors to smoking among women. However, specific health related behavioral and environmental factors linked to smoking were mentioned. It was stated that the smoking was most prevalent among lower income class. This implicates that poverty play an important role as an underlying cause of smoking. It sound logic that one of the sub-objectives should be stated clearly to take care of improving socio-economic situation or more accurately to tackle poverty related issues. It is also mentioned that the women’s concerns about weight gain following quitting act as a barrier to stop smoking. Luckily, More than one sub-objective took care of this factor.

Description of the intervention:

A good description of the intervention is provided in the article under specific headings. It was directed to two pairs of demographically matched counties in Vermont and New Hampshire in United States which were assessed preintervention and postintervention during the period 1989 to 1994. The project was initiated by organizing community planning groups and the program was called “Breath Easy”. Each county’s planning group formed a coalition, and each coalition formed 5 working groups. The planning process was taken up by the local planning group along with its coalition with very little input from the investigators except for the first year. Different activities were conducted during each year after the starting of the program. In the first year, the focus was to develop support systems to help women quit smoking through individual proactive telephone peer support. During the second year, videotape showing the process of quitting smoking was produced and distributed at no cost. In the third year, free smoking cessation classes were organized with a focus on dealing with negative affect. Later, the health professionals were involved in the “Breath Easy” program. Also, workplaces initiatives included presentations to businesses and worksites and assistance with smoking policies were started. Moreover, there was involvement of media initiatives included newsprint and radio (Secker-Walker et al. 2000).

The conceptual frame work and underlying theories and values:

The conceptual framework and underlying theories are not described in details in this article. It is only mentioned that they used social cognitive theory, the transtheoretical model of behavior change, diffusion of innovation theory, and communications theory. It was stated in the article that the project intervention was based on the proven effectiveness of this type of community intervention in promoting smoking cessation among women in Smoke Free North Side study. However, as I am reading the article it becomes clearer to me how well these theories could be fit into a community based health promotion project.

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The five basic stages of a behavior change as identified by the transtheoretical model of behavior change are pre-contemplation, contemplation, determination or preparation, action and maintenance (Nutbeam & Harris 2004). These stages could be applied to explain the change of smoking behavior among women especially ensuring maintenance through peer support. According to the social cognitive theory an individual, the environment and behavior are continuously interacting and influence each other (Nutbeam & Harris 2004). This is clearly noticed in the modifications of community norms concerning women smoking. The people decision to smoke is made within a broad context and influence by the surrounding environment which shapes the health behaviors such as smoking. In addition, diffusion of innovations refers to the spread of new ideas, techniques, behaviors or products throughout a population (Ferrence 1996) and this is exactly what had happened in this project where the message of smoking cessation was spread through mass media, videos and classes. Lastly, the communications theory is also applicable to this project.

The values are important things because they affect which issues we choose to address and how we are going to address them (Kahan & Goodstadt 2005). The values of community intervention and development were not mentioned in this article. After literature review, it became obvious that some of these values are respect, equity, participation and meaningful process (http://www.wrha.mb.ca/howcare/commdev/). The process of community participation allows removal of inequality barrier and ensures fair distribution of resources. Moreover, respecting of local people and their involvement in determining their own health problems resulted in a positive outcome of this project.

Application of Ottawa Charter action areas:

There are many social factors that affect the disease’s risk factors such as smoking and thus affecting the health. This includes low levels of social support and lack of personal control. These issues were well addressed in this initiative through the proper applications of Ottawa charter action areas. It is well stated that the achievement of the project objectives is through community members’ participation in planning and implementation. The community action is strengthened by involving local people to participate actively in order to improve their own health. The community organization is set up by forming local planning groups and from each group, the annual plans are drawn up.

The supportive environment is provided through the supportive telephone communications networks which were arranged to encourage women to stop smoking. In addition, a healthy and supportive environment was ensured in workplaces, community college and high schools. Moreover, the organization of free smoking classes that focus on dealing with negative affect following quitting played an important role to maintain the quitting process.

Healthy public policies were built in the community. An example is that smoking cessation policies were introduced into the workplaces. Another example was the active involvement of media which included newsprint and radio and made use of paid advertisements and thus information for quitting were available in each community. The personal skills of targeted females were developed. This was by training the female ex-smokers to provide support to current smokers to quit smoking through proactive telephone support. In addition, they were involved in the production of videos showing their own process of quitting smoking.

Re-orientation of health services took place to some extent. This was by mobilizing the health workers towards focusing on smoking cessation activities rather than providing the medical care only. This was through making referrals to the telephone peer support system and they were trained in a brief smoking cessation protocol. It is quit obvious that by analyzing the interventions of the project, the Ottawa charter definition of health promotion is clear. This is because the project interventions could be understood as a process of enabling people to increase control over, and to improve, their health (WHO 2005).

Evaluation:

The evaluation process plays an essential role in ensuring the best achievement of any given program as it will affect the way in which the program will be conducted and the amount of effort needed (Ewles & Simnett 1999). For the evaluation to be accepted, it should consist of process, impact and outcome evaluation. It is important to have the three parts otherwise it will be difficult to understand how the evaluation took place (Springett et al. 1995). The evaluation starts by evaluating the process including measuring the strategies, the activities and the quality of the project. Then, measuring the immediate effect of the project and this is called impact evaluation. At the end, it should measure the outcome or long term effect (Territory Health Services 2005).

The evaluation was well planned and was well in place for this project. They used PRECEDE frame work to integrate the overall objectives of the program with the evaluation plan. This model takes into account multiple factors that determine health and quality of life and generates specific objectives and criteria for evaluation (Green & Kreuter 1999). The design of the study was non-randomized with two pairs of demographically matched countries assessed peintervention and postintervension. This established a relationship between the intervention and observed outcome by comparing the situation before and after the intervention. In addition, they have set specific measurable objectives for each working group to be accomplished or initiated during the following 12 months.

The stages of evaluation were done as follows:

Process evaluation:

Specific factors were set to evaluate predisposing, reinforcing and enabling factors. These includes attitudes and beliefs towards quitting smoking, perceptions of norms and social supports, availability of smoking cessation materials and services, program recognition and media coverage. Suitable indicators were used to measure the above factors such as social support scale, measures of confidence in being able to stop smoking and confidence in being able to control weight gain after quitting smoking and measures for availability of smoking cessation resources.

Impact evaluation:

The impact was evaluated through a change in the smoker’s behavior. The indicators which were used are average daily cigarette consumption and average number of serious quit attempts.

Outcome evaluation:

This was evaluated by measuring the smoking prevalence among women aged 18 to 46 years old. It was found that the prevalence had declined significantly. This indicates the effectiveness of this project through achieving its main goal.

Summative evaluation:

It is the last step to be done and it involves considering the project as a whole, from beginning to end (SACHRU 2005). The investigators did not evaluate all different aspects of the project. However, they mentioned about strengths, limitations, response rate and their recommendations. The strengths of the study were small size and rural nature of these communities. On the other hand, the major limitations were nonrandomized design, the inclusion of only two counties in each condition, lack of prior measures of smoking prevalence in these counties and lack of ethnic diversity in the study population which limit the generalizability of the results. The overall sample size was 6436 with response rates of 89.9%. Their recommendations were that any future community interventions designed to effect reductions in smoking should place greater emphasis on the provision of a broad range of support for quitting smoking that is readily accessible to all smokers (Secker-Walker et al. 2000).

Conclusion:

Adoption of health promotion best practice is the only way to ensure effective and successful results of any intervention. However, this practice is not an easy mission. It requires a lot of augmentive efforts. The application of Ottawa charter and the reliance on justifying theories and values is essential. Moreover, the quality of the initiative is based on effective planning and evaluation from the initial stages. The community involvement in promoting smoking cessation was ensured in this project from the initial stages. Also, the evaluation process was proceeding well with PRECEDE framework. In conclusion, this initiative was about to be an excellent example of best practice except improper statement of objective, values behind the intervention and insufficient statement of needs assessment