Ecological Model vs Behavioral Model Tobacco Control

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.

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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, self-

confidence, 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.

c. 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).

d. Perceived Benefits: The believed effectiveness of strategies designed to

reduce the threat of illness.

e. Perceived Barriers: The potential negative consequences that may result

from taking particular health actions, including physical, psychological, and

financial demands.

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. The person must feel there is a ‘risk’ of continuing the current

behaviour.

c. The person must belief change will have ‘benefits’ and these need to

outweighs the ‘barriers`.

d. 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


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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

numerous-choices 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, socio-

economic, 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 the regulation of nicotine and tar

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 self-

quit 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.


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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


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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.


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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

Baum, F. (2008). The new public health. Australia: Oxford University Press.

BHF. (2001). Stopping smoking; Evidence base guidance. Retrieved May 1,

2008, from http://www.scribed.comSTOPPING 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.comSTOPPING

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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Ecological Model vs Behavioral Model Tobacco Control

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