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Critically compare a Behavioural Change approach with a comprehensive and integrative (Ecological Public Health) in smoking behaviour for

adolescents in Indonesia.

Name of Student: Ridwan Amiruddin Course : 7880 Health Determinants and Global Response

Critically compare a Behavioural Change approach with a comprehensive and integrative (Ecological Public Health) in smoking behaviour for adolescents in Indonesia. Introduction
This article critically compares a behavioural change approach with a comprehensive and integrative model in smoking behaviour for adolescents in Indonesia. Focus discussion provides implication of behavioural change approach and ecological public health approach to analyse behavioural smoking for adolescents. Tobacco use is a major public health problem in all countries. In the United States of America, tobacco use is the single leading preventable cause of death, accounting for approximately 430,000 deaths each year (WHO, 2008). As was documented extensively in previous Surgeon General’s reports, cigarette smoking has been causally linked to lung cancer and other fatal malignancies, atherosclerosis and coronary heart disease, chronic obstructive pulmonary disease, and other conditions that constitute a wide array of serious health consequences. More recent studies have concluded that passive (or involuntary) smoking can cause disease, including lung cancer, in healthy non-smokers. In Indonesia smoking prevalence among adults increased to 31.5% in 2001 from 26.9% in 1995 (MOH, 2008). In 2001, 62.2% of adult males smoked, compared with 53.4% in 1995. Only 1.3% women reported smoking regularly in 2001. Prevalence according by age group increases rapidly after 10 to 14 years of age among males: from 0.7% (1995) to 24.2% (2001) (MOH, 2008). Among youth ages 10 to 14 years old, the majority of those who ever use of tobacco were boys (about 92 percent). For both boys and girls, the highest proportion of ever use of tobacco was among those with age of 13 years old (about 41 percent) and followed by those with the age of 14 years old (about 23 Ridwan Amiruddin_Health Determinant_ Essay HBM and Ecological Model Juni 5, 2008. 2

percent). It seems that boys have experience in using of tobacco in earlier ages (10 and 11 years old) compared to girls (12 years old). The experience of youth tobacco use was dominantly among those who living in urban area (about 79 percent). Meanwhile, the major percentage of the youth tobacco use was in the level education of primary/middle school, followed  by  those with level education  of high school and illiterate (CHRUI, 2001). Risk factors for smoking initiation, surveys of current adult smokers reveal that almost 80% began smoking at 16 years of age or earlier (Jaen, 2000). Initiation of cigarette smoking is associated with multiple factors. Environmental factors include availability of cigarettes, the perception that tobacco use is the norm, peer and sibling attitudes, and lack of parental support during adolescence. Behavioural factors include low academic achievement, rebelliousness, alienation from school and lack of skill to resist offers of cigarettes. Personal factors include low self esteem and belief that smoking confers future advantages in social life. Others factors associated with initiation of smoking include price of cigarettes, cigarettes advertising and promotions, and degree of exposure to affective counter advertising and school-based prevention program.

Behavioural Change Model
Behaviour change theories and models from the social and behavioural sciences explain the biological, cognitive, behavioural, and psychosocial/ environmental determinants of health-related behaviours. Thus they also define interventions to produce changes in knowledge, attitudes, motivations, selfconfidence, skills, and social supports required for behaviour change and maintenance (Whitlock, at. al, 2002). The application of relevant theoretical models to behavioural interventions is an important contribution to strengthening health program, especially to reduce tobacco use.

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The Health Belief Model (HBM) is a psychological model that attempts to explain and predict health behaviors by focusing on the attitudes and beliefs of individuals. The HBM has been adapted to explore a variety of long- and short-term health behaviours, including sexual risk behaviors and the transmission of HIV/AIDS and tobacco control. The key variables of the HBM are as follows (Rosenstock, Strecher and Becker, 1994; Corcoran, 2007).
a.

Perceived Threat: Consists of two parts: perceived susceptibility and perceived severity of a health condition. E.g. tobacco use is the main risk factors that lead to death all over the world. In 2005 was 5.4 million people died from lung cancer, heart disease and other illness which related to tobacco (WHO, 2008).

b.

Perceived Susceptibility: One's subjective perception of the risk of contracting a health condition. Perceived Severity: Feelings concerning the seriousness of contracting an illness or of leaving it untreated (including evaluations of both medical and clinical consequences and possible social consequences).

c.

d.

Perceived Benefits: The believed effectiveness of strategies designed to reduce the threat of illness. Perceived Barriers: The potential negative consequences that may result from taking particular health actions, including physical, psychological, and financial demands.

e.

f.

Cues to Action: Events, either bodily (e.g., physical symptoms of a health condition) or environmental (e.g., media publicity) that motivate people to take action.

g.

Other Variables: Diverse demographic, sociopsychological, and structural variables that affect an individual's perceptions and thus indirectly influence health-related behaviour.

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Implication Health Belief Model for Quitting smoke
The model proposes that a person’s behaviour can be predicted based on how vulnerable the individual considers themselves to be. “Vulnerable” is expresses in the HBM through risk (perceived susceptibility) and the seriousness of consequences (severity). These two vulnerability variables need to be considered before a decision can take place. This means a person has to weigh up the cost/benefits (Naidoo and Wills 2000 cited in Corcoran, 2007) or pros/cons of performing behaviour (Corcoran, 2007; Kerr, 2000). The HBM includes four factors that need to take place for a behaviour change to occur: a. The person needs to have an ‘incentive’ to change their behaviour, For example: An “incentive” for a person to stop smoking could be desire not to smoke around a new baby. b. c. d. The person must feel there is a ‘risk’ of continuing the current behaviour. The person must belief change will have ‘benefits’ and these need to outweighs the ‘barriers`. The person must have the ‘confidence’ (self-efficacy) to make the change to their behaviour. Thus, individual may be more likely to stop smoking if they are aware of the health consequences and think they are vulnerable to (e.g. lung cancer). Connected with their risk assessment is their belief in the cessation of smoking benefiting their health and whether it will have any other benefits. However, the individual may decide that the long term benefits of giving up smoking are not worth the short term problems of nicotine withdrawal and missing the pleasure of smoking. Outside forces (including the health warnings on cigarette packets) may motivate or maintain behavioural change. The health belief model maintains that ‘cues’ to behaviour change are important. The health belief model has been most useful when applied to relatively straightforward actions (Nutbeam, 2006). It has Ridwan Amiruddin_Health Determinant_ Essay HBM and Ecological Model Juni 5, 2008. 5

been less effective in long term, complex and socially determined behaviour changes. Despite its limits it has proved useful in informing campaign about the need to consider the ways in which beliefs can determine changes in behaviour (Baum, 2008). Smoking cessation at any age can prevent much of the future risk of tobacco-related diseases. In 2004, an estimated 14.6 million (40.5%) adult smokers had stopped smoking for at least 1 day because they were trying to quit; however, about 5% are successful in quitting for at least 1 year. 37,38% Clinicians play a critical role in encouraging smokers to quit and in providing or referring patients to appropriate counselling and treatment (Vilma, 2006). The essential features of smoking cessation advice by health care providers are known as the 5 A’s: ask about tobacco use, advise to quit, assess willingness to make a quit attempt, assist in the quit attempt, and arrange timely follow up. All health professionals and particularly those in primary care (because of the extent and ease of access to smokers) have a vital role in helping smokers to stop (BHF, 2001). The basic essentials are to: Ask about and record smoking status, keeping the record up to date Advise smokers of the benefits of stopping in a personalised and appropriate way, relating this to patient concerns and any health problems where possible. Assess motivation to stop - and reinforce if possible. Smokers are much more likely to stop after suffering an acute event such as myocardial infarction after which about 20% quit smoking. Assist smokers to stop: this to include useful tips on how best to try, the offer of support and considerations of either NRT (nicotine replacement therapy) *or bupropion * (with accurate information and advice about these). Arrange follow-up if possible - or review when next seen. Alternatively refer the patient to a specialist smoking cessation service.

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Ecological Public Health Model
Ecological Public Health as an ecological framework for the development of health policy is, in essence, an integrated approach. Focussed on prevention, its component policies and strategic thrust aim toward developing opportunities for health-making choices by organizations and individuals. Its policy components would be designed to make the creation and maintenance of healthful environments and personal habits the easiest the ‘cheapest’ and most numerouschoices for selection by governmental units and corporations, producers and consumers, among all the options available to them. Policies would emphasize the aspects of environments and ways of living which have largest potential for promoting health (Milio in Chu, 2008). Ecological public health is an extension of the new public health with health viewed in a holistic sense and the recognition that one’s physical, mental and social wellbeing are determined by the interaction of environmental, socioeconomic, cultural, political and personal factors’. Public policies must rely on health impact in terms of sustainable health for people. These policies have to consider ‘equity, sustainability, conviviality and preservation of the global environment’ (Chu, 1994). Ilona Kickbusch (1989) and Chu (2007) suggested that the concept of an ecological public health has emerged in response to a new range of health risks associated with the global ecological issues and the social cultural and economic patterns of our societies. Thus, the ecological public health an extension of the new public health with health viewed in a holistic sense, and the recognition that one’s physical , mental an social well beings are determined by the interaction of environmental, socio economic, cultural, political and personal factors. A key characteristic of the ecological model is the notion of connectedness between human beings, their physical and social environment and their health. The thrust of the action-oriented ecological public health is to integrate environment and health through intersectoral corporation (Chu, 2008).

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Implication Ecological Public Health for smoking behaviour
Integrative program to control tobacco is motivational interventions. One method of motivating smokers to quit is through tobacco control. This include legislation to ban tobacco advertising and sale to young people, health education, taxation to increase cigarettes prices, restriction of smoking in public space, and product modification through content (Reid 1996; Rutter, 2002). However, another large-scale community intervention in the USA, the community intervention trial for smoking cessation, which took place over 4 years and involved 22 communities (half receiving a community intervention and half acting as control), indicated no difference in the cessation rate for heavy smokers (COMMIT, 1995; Rutter, 2002). Foulds (1999), suggested that the result might have occurred because, in communities or countries where the health education message for anti-smoking is accepted and motivation for quitting is already high, motivational interventions will produce only small effects and will have a negligible impact on heavy, highly addicted smokers (Surgeon General Report, 2000). In develop countries the focus may need to be on individual treatment interventions, including specialist smoking clinics and strategies to improve selfquit attempts (Rutter, 2002). Although previous empirical studies have shows that tobacco control policies are effective at reducing smoking rates, such studies have proven of limited effectiveness in distinguishing how the effect of policies depend on the other policies in place, the length of adjustment period, the way the policy is implemented and the demographic groups considered (Levy, 2005). Barrier to ecological public health model is this model requires health promotion to move out from the traditional health domain into a wider arena of social and environmental practitioners is to overcome institutional constraints and to break down the traditional disciplinary and territory barriers which obstruct practice of the intersectoral activities required to integrate environmental and health sectors. the regulation of nicotine and tar

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Labonte (1992) provides a different perspective on approach to health. He identified three model of health: medical or high-risk approach, behavioural or multiple risk factor reduction approach, a socio-environmental or community development (Labonte, 1992). He explains that the medical approach is reductive and precise in focus; the behavioural approach accommodates the medical approach and broadens it to incorporate behaviours and other factors that influence those particular behaviours; and the socio-environmental approach, which accommodates both previously mentioned models, is more inductive than deductive and is broad ranging and multidimensional when seeking explanatory relationship and planning ways to address health problem (Johnson, 2007). Within the environmental determinants of health literature, attention is being given to what constitutes health in terms of place or physical settings (Baum, 2008). The Ottawa charter for Health Promotion (WHO, 1986) identified the impact of setting of everyday lives as the place where we ‘live, work, play, and love’. The WHO delineates between contextual setting and elemental settings. Contextual settings comprise the broader setting, such as cities, suburbs, villages and island that play a major role in determinants a community level of access to services and other social determinants of health. Element settings include schools, homes, workplaces, hospital, marketplaces and other similar settings that impact on the health of local communities (Jonhson, 2007). Kerr (2000) identified that treating diseased or high risk individual does not have much of an impact on the health of the populations a whole. But changing a risk factors across a whole population by just small can have a large impact on the incidence of a disease or problem in the community e.g. tobacco use. Tobacco use affects for almost degenerative disease, reducing incidence rate tobacco use affect significantly for lung cancer, coronary heart disease and pulmonary disease. Smoking bans in public places, whether mandated or voluntary, are effective methods for reducing people’s exposure to second hand smoke. In addition to protecting non smokers from involuntary exposure to tobacco smoke toxins, such policies reduce cigarette smoking and may increase quitting rates Ridwan Amiruddin_Health Determinant_ Essay HBM and Ecological Model Juni 5, 2008. 9

among adult smokers. For example, workplace smoking bans reduce smoking prevalence by approximately 10% and reduce cigarette smoking by 29%. Restrictions on smoking in public places also produce environments in which smoking is marginalized (Klarck, 2006). Further more In the USA, Fichtenberg (2002) identified totally smoke-free workplaces are associated with reductions in prevalence of smoking of 3.8% and 3.1 fewer cigarettes smoked per day per continuing smoker. Combination of the effects of reduced prevalence and lower consumption per continuing smoker yields a mean reduction of 1.3 cigarettes per day per employee, which corresponds to a relative reduction of 29%. There are several laws and regulations which are directly or indirectly related to tobacco control in Indonesia, such as National Law No. 23 on Health, Governmental decree No 81 about smoking and health as well as some local regulation such as in Jakarta Bogor cities. But, these regulations have two important limitations. First, they are not strong enough and do not cover all aspect of a comprehensive tobacco control program, and secondly those regulations have not been fully implemented or enforced. Tobacco control in Indonesia will not move forward until the government evaluates and strengthens existing laws, considers passing new strong laws and develops protocols for enforcing all laws.

Conclusion
Prevalence rate tobacco use in Indonesia increases rapidly, among youth ages 10 to 14 years old, the majority of those who ever use of tobacco were boys (about 92 percent). For both boys and girls, the highest proportion of ever use of tobacco was among those with age of 13 years old (about 41 percent) and followed by those with the age of 14 years old (about 23 percent). Tobacco use is a behavioural analysis related with behaviour change. In the HBM, the model proposes that a person’s behaviour can be predicted based on how vulnerable the individual considers themselves to be “Vulnerable” is expresses in the HBM through risk and the seriousness of consequences. Ridwan Amiruddin_Health Determinant_ Essay HBM and Ecological Model Juni 5, 2008. 10

Integrative program to control tobacco is motivational interventions. One method of motivating smokers to quit is through tobacco control. This include legislation to ban tobacco advertising and sale to young people, health education, taxation to increase cigarettes prices, restriction of smoking in public space, and product modification through the regulation of nicotine and tar content. It has identified that treating diseased or high risk individuals does not have much of an impact on the health of the populations a whole. Changing risk factors across a whole population by just small can have a large impact on the incidence of a disease or problem in the community.

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Reference lists
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STOPPING OKING

Campos-Outcalt, D. & Weiss, B.D. (2000). (Eds). Preventive health care. Jaen C.B. (2000) Smoking prevention and cessation. USA: McGraw-Hill. Clarck, P. (2006). Impact of home smoking rules on smoking pattern among adolescents and young adults. Preventing chronic disease. Public health research, practice, and policy. Retrieved May 1, 2008, from http://www.scribed.com

STOPPING

COMMIT Research Group. (1995). Community intervention trial for smoking cessation (COMMIT): II. Cohort results from a four year community intervention. American journal of public health, 85: 193-200. Retrieved April 28, 2008, from http://www.commit.com Corcoran, N. (Ed). (2007). Communicating health strategies for health promotion. London: Sage Publication. Ltd. Chu, C. (1994). Integrating health and environment: The key to an ecological public health. In C. Chu & R. Simpson. (Eds.). Ecological public health: From vision to practice. Brisbane: Watson Ferguson & Co. Chu, C. (2008). Health determinants and global response. The Griffith School of Environment. Fichtenberg, C.M. (2002) Effect of smoke-free workplaces on smoking behaviour: systematic review. BMJ, 325, 188-191. Foulds, J. (1999). Nicotine replacement therapy: Available, abuse liability and dependence potential in tackling tobacco. Cardiff: Health Promotion Wales. Johnson, A. & Paton, K. (2007). Health promotion and health services. USA: Oxford University Press. Kerr, J. (Ed). (2000). Community health promotion; Challenges for practice. United Kingdom: Harcourt Publisher Limited.

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Labonte, R. (1992). Heart health inequalities in Canada. Model’s theory and planning, health promotion international. Canada: Oxford University Press. Retrieved May 1, 2008, from http://heapro.oxfordjournals.org/cgi/content/ abstract/7/2/119 MOH, (2008). Tobacco consumption & prevalence in Indonesia. Retrieved May 1, 2008, from http://www.litbangkes.depkes.go.id. Nutbeam, D., & Smith, C. (1993). Maintaining evaluation design in long term community based health promotion program: The heart beat Wales experience. Epidemiology and community health 47,. 127-133. Rutter, D., & Quine, L. (2002). Changing health behaviour. Philadelphia: Open University Press. Whitlock, E. P., Orleans, C.T., Pender, N., & Allan, J. (2002). Evaluating primary care behavioural counselling interventions: An evidence-based approach. Am Journal Preventive Medicine. 22, 267-284.

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