Abstract
BACKGROUND:
Four out of five people who use tobacco begin before they reach adulthood. Schools provide the opportunity to address the young population before they initiate tobacco use. Different health education approaches have their unique merits and demerits. The present study aims to assess the use of various approaches for effective communication with students regarding tobacco hazards.
MATERIALS AND METHODS:
It was a health education intervention study done at a Government School in Dadra and Nagar Haveli district. The students of class IX and class XI of Government School were educated about the harmful effects of tobacco and government regulations against tobacco use using various methods of health education; chalk and talk, panel discussion, roleplay, pamphlet distribution, etc., The Student “t” test was used to compare scores obtained by students before and after the intervention. The Chi-square test was used to test associations between variables. Bonferroni post hoc test was used to test for significant differences between various methods of health education imparted to students.
RESULTS:
A total of 367 students participated in the study, with females comprising 53% of the sample. The mean age of the students was 15.7 years (±1.05). The study found the magnitude of a statistically significant increase in mean score percentages for knowledge through various health education methods: chalk and talk (37.0%, P < 0.0001), pamphlet (26.65%, P < 0.0001), roleplay (20.83%, P = 0.0003), panel discussion (14.7%, P = 0.0009), poster (12.6%, P = 0.0025), symposium (8.4%, P = 0.0221), and leaflet (−4.0%, P = 0.0382). Furthermore, the Bonferroni post hoc test demonstrated that the chalk-and-talk method was more effective in enhancing knowledge, while the leaflet method was more influential in shaping attitudes.
CONCLUSIONS:
The chalk-and-talk method is the most effective health education method for awareness of tobacco hazards among class IX and XI students. While planning for health education dissemination, the approach should be chosen wisely considering the content to be delivered.
Keywords: Health education, school, students, tobacco
Introduction
As per National Family Health Survey 5, 38% of men and 3.9% of women aged 15–49 years use any kind of tobacco in India; these proportions are higher in rural areas. All forms of tobacco use are dangerous to our health.[1] Smokers harm the health of nonsmokers through tobacco smoke, and people who chew tobacco harm nontobacco chewers’ health with their spit. Tobacco use can cause respiratory illnesses like pneumonia and bronchitis, middle-ear disease in young people, and cancers of the lungs and other organs.[2]
India has been grappling with the problem of tobacco use among its youth for a long time. According to the India Global Youth Tobacco Survey,[3] conducted among students in Classes 8, 9, and 10, around 14.6% of students were currently using tobacco in any form. This alarming statistic highlights the urgent need for tobacco use prevention efforts in the country. The survey also found that 4.4% of students smoked cigarettes, while 12.5% were using some other form of tobacco.[3] The more concerning fact is that four out of five people start consuming tobacco before they reach adulthood.[4] This means that adolescence is the best suitable period for tobacco use prevention efforts. Schools can play a crucial role in educating young people about the dangers of tobacco use and helping them make informed decisions.[5]
By providing students with accurate and up-to-date information about the health consequences of tobacco use, schools can help to create a culture that discourages tobacco use. One way to do this is through health education programs that teach students about the risks associated with tobacco use and the benefits of maintaining a healthy lifestyle. Health education programs offer advantages beyond just controlling the transmission of diseases. They serve as valuable tools for preserving well-being, enhancing cognitive capabilities, and promoting healthy habits.[6] Schools can also create a supportive environment for students who want to quit using tobacco by providing resources and support services.[5] In addition to education programs, it is also important to enforce existing rules and regulations regarding smoking and spitting in public places. By involving students in raising community awareness about these rules, schools can help to create a culture that promotes healthy habits and discourages tobacco use. These health education activities should help the students to acquire the knowledge, attitude, and skills that enable them to make informed choices and decisions. Young people need to understand the consequences of tobacco use and tobacco advertising in public places and the long run, to adopt and practice behavior conducive to health.[7] Various tobacco control policies have been implemented to reduce tobacco use, including high taxation, health warnings, marketing restrictions, and smoking bans in public places.[8] In addition to these policies, health education is crucial in preventing tobacco use among young people. To the best of our knowledge, the published literature on the effectiveness of health education methods focuses on single or two methods, while our study has compared seven popular methods of delivering health education regarding tobacco hazards to school-going students. The aim of this study was to assess the effectiveness of different health education methods for tobacco hazards among school students.
Materials and Methods
Study design and setting
This study was a Health Education Intervention study conducted at a government school located in a rural area of Silvassa district in the UT of Dadra and Nagar Haveli and Daman and Diu.
Study Participants and sampling
The study included 367 students in grades IX and XI. Undergraduate medical students in their third academic year were trained to conduct health education sessions in school classrooms using various methods, including chalk and talk, panel discussion, roleplay, pamphlet distribution, and other interactive methods. The medical students were randomly assigned to classes and were responsible for conducting the health education sessions. The medical students delivering health education ensured that the contents of the session were similar in all the classes and only the way of delivering the information will differ in each class.
The sessions focused on the harmful effects of tobacco use and the COTPA Act, which regulates tobacco use in public places. The sessions were conducted in school classrooms during regular school hours, and each session was approximately 45 min long. Pre- and post-intervention surveys were conducted to assess the effectiveness of the health education sessions. The surveys included questions related to knowledge about the harmful effects of tobacco use and the COTPA Act. The surveys were administered to all study participants before and after the health education sessions.
Data collection tool and technique
A predesigned semi-structured questionnaire was developed by the investigators based on prevalent community perception and practice of tobacco use in the local language and given in printed form before and after the health education intervention. The questionnaire had two tools:
Tool A: This tool assessed the questions related to the knowledge regarding the harmful effects of tobacco use, availability of de-addiction services in the area, awareness about anti-tobacco legislation, etc.
Tool B: This tool assessed students’ attitudes and perceptions of tobacco use and its social approvals.
Statistical analysis
In this study, the effectiveness of a health education intervention was evaluated by comparing scores obtained by students before and after the intervention. The responses were entered into Microsoft Excel and analyzed using SPSS 20.0, Armonk New York. To test for significant differences in knowledge and attitudes, several statistical tests were applied. The Student “t” test was used to compare scores obtained by students before and after the intervention. The Chi-square test was used to test associations between variables. Finally, the Bonferroni post hoc test was used to test for significant differences between various methods of health education imparted to students.
Ethical consideration
Institutional Ethics Committee permission was obtained before the study (DMHS/IEC/2016/214/2288). Permission from the school principal was also obtained before the intervention. Students and class teachers were informed regarding the purpose and type of study intervention before commencing data collection.
Results
The study included a total of 367 students studying in classes IX and XI at a government school in the rural area of the Silvassa district. Among the students, 53% were female, and the mean age was 15.7 (±1.05) years [Table 1].
Table 1.
Distribution of students and different methods of health education (n=367)
| Method of health education | Gender (n %) |
Age |
Total (%) | ||
|---|---|---|---|---|---|
| Female | Male | Mean (Years) | Standard deviation | ||
| Chalk and talk | 10 (33.3) | 20 (66.7) | 16.5 | 0.629 | 30 (8.2) |
| Leaflet | 42 (51.9) | 39 (48.1) | 14.6 | 0.660 | 81 (22.1) |
| Pamphlet distribution | 39 (58.2) | 28 (41.8) | 16.5 | 0.745 | 67 (18.3) |
| Panel discussion | 41 (51.9) | 38 (48.1) | 15.7 | 0.986 | 79 (21.5) |
| Poster presentation | 21 (56.8) | 16 (43.2) | 15.0 | 0.687 | 37 (10.1) |
| Roleplay | 23 (60.5) | 15 (39.5) | 16.3 | 0.582 | 38 (10.4) |
| Symposium | 19 (54.3) | 16 (45.7) | 16.5 | 0.562 | 35 (9.5) |
The undergraduate medical students provided health education to the school students using different methods such as panel discussions, leaflet distribution, and pamphlet distribution activities. These methods were repeated twice to ensure that all students received the benefit of the health education intervention.
The mean scores of students improved in all health education methods except in the leaflet method, where some students did not answer some questions on the post-intervention questionnaire. The maximum improvement was shown by the chalk-and-talk method (36.96%), followed by pamphlets (26.65%), and roleplay (20.8%) [Table 2].
Table 2.
Percentage increase in mean score by various health education methods (n=367)
| Health education method | Mean pre-intervention total score (out of 10) | Mean post-intervention total score (out of 10) | Change in score (%) |
|---|---|---|---|
| Chalk and talk | 6.133 | 8.400 | 36.96 |
| Pamphlet distribution | 5.433 | 6.881 | 26.65 |
| Roleplay | 5.684 | 6.868 | 20.83 |
| Panel discussion | 4.987 | 5.722 | 14.72 |
| Poster presentation | 5.784 | 6.514 | 12.62 |
| Symposium | 6.143 | 6.657 | 8.37 |
| Leaflet | 8.654 | 8.309 | −3.99 |
The post-intervention correct responses of the students were analyzed for each method of health education. The analysis showed that the chalk-and-talk method had the highest number of correct responses to questions related to the presence of tobacco in Gutkha sachets, harmful effects of Gutkha consumption, smoking at public places is not allowed, fines for smoking in public places, and the number of harmful substances in tobacco. On the other hand, the symposium method was most effective in addressing students’ perceptions that the use of Gutakha/Bidi does not impress friends [Table 3].
Table 3.
Correct responses of students after health education sessions using various methods (n=367)
| Question | Chalk and talk n (%) | Symposium n (%) | Poster presentation (%) | Roleplay n (%) | Pamphlet distribution n (%) | Panel discussion n (%) | Leaflet n (%) |
|---|---|---|---|---|---|---|---|
| There can be tobacco in Gutkha Sachets | 29 (96.67) | 26 (74.29) | 27 (72.97) | 31 (81.58) | 60 (89.55) | 65 (82.28) | 75 (92.59) |
| Gutkha consumption is harmful | 28 (93.33) | 30 (85.71) | 26 (70.27) | 29 (76.32) | 53 (79.1) | 63 (79.75) | 72 (88.89) |
| Gutkha use doesn’t impress friends | 16 (53.33) | 28 (80) | 22 (59.46%) | 20 (52.63) | 39 (58.21) | 36 (45.57) | 64 (79.01) |
| Passive smoke injures us | 25 (83.33) | 28 (80) | 29 (78.38) | 31 (81.58) | 52 (77.61) | 60 (75.95) | 68 (83.95) |
| Use of Bidi/cigarette doesn’t impress friends | 18 (60) | 30 (85.71) | 26 (70.27) | 17 (44.74) | 45 (67.16) | 38 (48.1) | 68 (83.95) |
| Legal age for selling tobacco products | 25 (83.33) | 14 (40) | 29 (78.38) | 32 (84.21) | 41 (61.19) | 43 (54.43) | 75 (92.59) |
| Smoking in public places is not allowed | 29 (96.67) | 34 (97.14) | 35 (94.59) | 36 (94.74) | 62 (92.54) | 74 (93.67) | 73 (90.12) |
| Rs. 500 fine for smoking in public places | 25 (83.33) | 0 (0) | 13 (35.14) | 3 (7.89) | 54 (80.6) | 25 (31.65) | 30 (37.04) |
| Number of harmful substances in tobacco | 29 (96.67) | 16 (45.71) | 0 (0%) | 28 (73.68) | 7 (10.45) | 1 (1.27) | 70 (86.42) |
| 100 meters area around the school is prohibited for tobacco sell | 28 (93.33) | 27 (77.14) | 34 (91.89% | 34 (89.47) | 48 (71.64) | 47 (59.49) | 78 (96.3) |
Bonferroni post hoc test was applied to test the superiority of a particular health method with all the applied methods regarding the questions that assessed students’ knowledge and attitude to tobacco product use. As per Table 4, it is evident that the chalk-and-talk method maximally improved students’ knowledge and attitude toward tobacco products, and it differed significantly from other health educational methods in the majority of the questions. However, for attitude-related questions, the leaflet method was significantly different from other methods.
Table 4.
Bonferroni post hoc test for the effectiveness of the health education method
| Question | Method 1 | Method 2 | Mean difference | Standard error | P |
|---|---|---|---|---|---|
| Gutkha can impress friends | Leaflet | Panel discussion | 0.334* | 0.075 | 0.000 |
| Use of Bidi/cigarette impresses friends | Leaflet | Roleplay | 0.392* | 0.089 | 0.000 |
| Legal age for selling tobacco | Leaflet | Symposium | 0.526* | 0.086 | 0.000 |
| Pamphlet | 0.314* | 0.070 | 0.000 | ||
| Panel discussion | 0.382* | 0.067 | 0.000 | ||
| Fine for smoking in public places | Symposium | Chalk and talk | −.833* | 0.103 | 0.000 |
| No. of harmful substances in tobacco | Leaflet | Poster | 0.864* | 0.061 | 0.000 |
| Symposium | Chalk and talk | −.510* | 0.076 | 0.000 | |
| Roleplay | Poster | 0.737* | 0.071 | 0.000 | |
| Pamphlet | Chalk and talk | −.862* | 0.067 | 0.000 | |
| Panel discussion | Chalk and talk | −.954* | 0.066 | 0.000 | |
| Poster | Chalk and talk | −.967* | 0.075 | 0.000 | |
| The area around the school prohibited tobacco use | Leaflet | Panel discussion | 0.368* | 0.059 | 0.000 |
| Panel discussion | Chalk and talk | −.338* | 0.080 | <.001 |
Discussion
Our study focused on assessing the effectiveness of various health education methods in increasing school students’ knowledge about the harmful effects of tobacco and the COTPA Act.
It is crucial to sensitize medical students about the significance of health education in tobacco prevention since they are future physicians. Brinker et al. conducted a prospective quasi-experimental study that assessed the efficacy of two 60-min school-based modules provided by medical students in secondary schools in Germany. The study aimed to reduce smoking prevalence among adolescents aged 11–15 years at a six-month follow-up. In the control group, the percentage of smoking students increased from 4.2 to 8.1%, whereas it remained nearly unchanged in the intervention group. As a result, medical students can effectively participate in tobacco prevention programs in schools.[9]
In the majority of studies, educational interventions have been shown to improve awareness levels in various health-related areas. Ghate et al. conducted a study in Maharashtra using a PowerPoint presentation, a short film, and the “No Tobacco Pledge” for students. Following the program, almost 97.4% of students believed that it would assist in preventing tobacco use, and 82.1% said they would be “proud to remain tobacco-free for the rest of their lives.”[10]
Another study in Kerala by Parambil et al. compared the effectiveness of an educational short film on tobacco awareness with traditional lecture-based methods. Both approaches significantly improved students’ awareness levels. Short films were deemed effective in generating awareness about tobacco hazards among students through entertaining messages. Based on our findings, the chalk-and-talk method demonstrated the highest increase in the post-educational session score at 36.96%.[11]
In Indonesia, Kristina SA et al. evaluated the efficacy of a tobacco education program for pharmacy students that consisted of four sequential modules (3-h lectures) and three case scenarios (3-h roleplay). The study showed that this program had a beneficial impact on students’ knowledge, perceived role, self-efficacy, and ability to conduct tobacco cessation counseling.[12]
Another study was done in Iran by Hatami et al. to assess the effect of peer education in school on sexual health knowledge and attitude in girl adolescents. They observed that the mean score of knowledge and attitude toward all sexual health dimensions during puberty in the intervention group was significantly higher after the intervention (P < 0.05). In addition, there was a significant difference between the mean score of knowledge and approach toward all the aspects of sexual health of both the studied groups.[13]
It has been emphasized by researchers that merely adding content is not sufficient to effectively convey a message. Instead, more active and effective methods should be employed to disseminate it, particularly about attitudes. In our study, the symposium method was found to result in more accurate responses to attitude-related questions. This finding is consistent with the results of previous studies conducted by Hymowitz et al. (2007),[14] and Spangler et al. (2002).[15]
To decrease tobacco use, the Government of India introduced a Cigarettes and Other Tobacco Products Act (COTPA)[16] that prohibits smoking in public places, the sale of tobacco products to and by minors, and the sale of tobacco products within 100 yards of educational institutions. A study was done by Vasudevan et al.[17] to assess the implementation and awareness of COTPA in schools of Kerala found that the total awareness score of students was 13.1% (range 1.2–37.3%) and the student group showed the highest awareness of the provisions related to “locations of the smoking ban” (37.3%) and the provision with the least awareness among students was “punishments for violation” (1.2%). In our study, we observed that following a health education activity, there was a significant enhancement in school students’ understanding of these aspects of the COTPA Act.
Limitation and recommendation
The study has some limitations as follow-up of students was not done so the long-term effect of the intervention could not be assessed. The study could be compromised by social desirability bias by the students at the time of data collection.
Conclusion
Based on the available evidence, the chalk-and-talk method appears to be the most effective health education method for raising awareness of tobacco exposure among school students. Effective health education is crucial in promoting healthy behaviors and preventing the harmful effects of tobacco exposure. By choosing the most suitable method for delivering health information, we can ensure that students receive the knowledge and skills they need to make informed decisions about their health.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
We would like to extend our sincere gratitude and appreciation to the students who participated in this research article. Their invaluable contributions and willingness to share their time, insights, and experiences have been integral to the success of this study.
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