32 Effect of Transtheoretical Model Based Intervention Program on Cigarette Smoking Cessation among Technical Secondary School Male Students in Zagazig City Randa M. Said1, Noha M. Abdelsalam 2* 1 Department of Family Medicine, Faculty of Medicine, Zagazig University 2 Department of Public Health and Preventive Medicine, Faculty of Medicine, Zagazig University Abstract: Background: Interventions via cognitive-behavioral strategies are promising in smoking cessation among adolescents, by using the Transtheoretical model (TTM). Objective: To assess the effect of TTM- intervention program on smoking health risk, stages and process of change in smoking cessation, , decisional balance, and self-efficacy among technical secondary school male students in Zagazig city. Methods: A quasi-experimental study conducted in two randomly selected technical secondary schools in Zagazig city, Sharkia Governorate, Egypt. Male smokers from one school assigned as an experimental group and those from the other school as a control group. The experimental group received interventions based on the stage of behavior change through group counseling followed by individual phone counseling for 10 months. Intervention evaluation was done through self-reported questionnaires assessing knowledge and TTM outcomes. Results: After the intervention, participants in the experimental group (32%) progressed from lower to higher stages of behavior change compared with those in the control group (1.9%). The participants who reached action/maintenance stage were 13.9% in the experimental group versus 1.9% in the control group. There was a significant difference between two groups in the mean scores of knowledge, processes of change, decisional balance and self efficacy (P < 0.000). Conclusion: The TTM-based smoking cessation intervention program was effective in inducing a positive movement in the stages of behavior change among adolescent smokers through improving knowledge, experiential and behavioral processes, decisional balance and self-efficacy. Keywords: Adolescents, Decisional balance, Process of change, Stage of change, Self-efficacy. Introduction: Smoking is the most important 80% of regular adult smokers begin tobacco preventable cause of morbidity and mortality use before the age of 18.(3) Initiation of worldwide. The World Health Organization cigarette smoking in adolescence will be reported an increasing trend in prevalence of associated with difficulties to quit smoking in tobacco smoking among Egyptian male adulthood.(4) Adolescent smokers tend to adolescents from 23.8% in the year of 2000 to underestimate the addictive nature of nicotine 29.9% in 2010 and predicted to reach 43.7% although they rapidly develop nicotine by 2025.(1) Early initiation of cigarette dependence within 2-3 years.(5) A significant smoking during adolescence is a strong number of adolescents who use illicit drugs predictor of smoking in adulthood.(2) Over smoked cigarettes first.(6) Therefore, Corresponding author: Email: [email protected] 33 prevention and control of smoking among measure the effectiveness of the TTM in adolescents should be focused on adolescent smoking behavior. The main study intervention. objective to assess the effect of TTM-based Some meta-analysis studies found on knowledge intervention of smoking health smoking cessation interventions among risk, stages of smoking cessation, processes of adolescents which applied cognitive- change, decisional balance, and self-efficacy behavioral strategies were promising but did among technical secondary school male not recommend any specific model for students in Zagazig city. widespread implementation.(7) The Subjects and methods: This study is a quasi- transtheoretical model is a stage-based theory experimental study. It was conducted on two of behavior change. The stages of change experimental and control groups over a period (SOC) which represents the core construct of of 12 months from September 2016 to the model are pre-contemplation, October 2017. Through simple random contemplation, preparation, action, and sampling, two out of five technical secondary maintenance. Going through these stages is schools for males at Zagazig city selected as hypothesized by the processes of change an experimental group and a control group. (POC), decisional balance, and The sample size was calculated through Epi- temptation/self-efficacy which represent the Info (Epidemiological information package) other constructs of the model. (8) software version 6, according to the following The TTM has been widely used in data; confidence interval 95%, power 80%, research. Findings from trials comparing effect 25%, the effect size due to the interval TTM- interventions to control were 21% and the risk ratio 4.4,(7) so the calculated disappointing either negative or positive. sample size was 148 subjects. However, the evidence from these trials is Sample size was divided equally between unclear because many of them have stage experimental and control groups. A total specific rather than the entire TTM stages. sample of 113 participants (59 in the Moreover, negative trials might be attributed experimental group and 54 in the control to the formulation of the intervention rather group) completed all assessments used for than TTM theory. (9) final analysis. The study included all the The intervention program used all the recruited smokers regardless their gender and TTM constructs. The research aims to age. The participants with lost to phone Egyptian Family Medicine Journal (EFMJ) Vol .2(2), November 2018 www.efmj-eg.org 34 contact, inability to complete post-test, degree of importance of each absence from group counseling sessions and statement to their decision to smoke on refusing twice to accept phone counseling a five-point Likeret scale with total were excluded from the study. score= 100 points divided equally Tools of the study: The tools of the study between pros and cons. Reliability included the following:- Cronbach’s Alphas ranged from (0.56- 1. Smoking assessment questionnaire: it 0.67) for Pros and (0.51-0.61) for assessed the smoking history and Cons.(11) nicotine dependence level according to c. Smoking cessation self-efficacy Modified Fagerström Tolerance scale: It was a 20-items self-report Questionnaire for Adolescents.(10) measure scored on a five-point Likeret 2. TTM constructs questionnaires: It was scale with total score= 100 points. It translated into Arabic then validated examined a degree of confidence for through a back translation technique and smokers to resist the temptation of pilot testing, included: smoking. Reliability Cronbach’s a. Stages of change questionnaire: Alphas ranged from 0.92-0.95.(12) Participants selected one of five d. Process of change questionnaire: statements best representing their Experiential and behavioral processes current intentions of quitting smoking of change were assessed by a 40 items including pre-contemplation (no self-report measure scored on a five- intention to quit within the next 6 point Likert scale with total score= months), contemplation (consider 200 points divided equally between quitting in the next 6 months), Experiential and behavioral processes preparation (plan to quit in the next 30 of change. The participants indicated days), action (quit smoking within the how often they may use each thought last 6 months) and maintenance (quit or situation to help them avoid smoking more than 6 months ago).(8) smoking in the last month. Reliability b. Smoking Decisional Balance scale: It Cronbach’s Alphas ranged from 0.69- was a 20-items self-report measure of 0.92.(13) a participant’s pros and cons of 3. Knowledge and perception of health smoking. The participants rated the risks of smoking questionnaire: It was Egyptian Family Medicine Journal (EFMJ) Vol .2(2), November 2018 www.efmj-eg.org 35 adapted from Yang et al. Translated into Second phase: Intervention (TTM based Arabic then validated through a back intervention program): The intervention translation technique and pilot testing. It carried out for the experimental group during consisted of two parts: (a) eight the period from the middle of October 2016 to questions on knowledge about health end of November 2016 with follow up for ten hazards of smoking. Responses were months for each participant. The control coded as 0 for ‘no/don’t know’ versus 1 group did not receive any intervention. In the for ‘yes’, (b) six questions on risk school selected as the experimental group, the perception of smoking including participants were divided into groups agreement with three statements according to their stage of change. The according to a five-point Likert scale. intervention was in the form of group Three additional questions with response counseling sessions followed by individual categories of 0= ‘don’t know’, 1= ‘not at monthly phone counseling. all’, 2= ‘a little’, and 3= ‘very much’. All sessions held in the teachers' meeting The total score of knowledge and room during the students' activity periods. perception was 32 points with higher Each session lasted 45 minutes. The scores indicating better knowledge and interventional program activities were tailored perception.(14) Pilot study was conducted on the stage of change taking into in September 2016 on 15 students who consideration the other psychological were excluded from the study to check constructs of the model as summarized in the validity of the questionnaires. Appendix(1). Field-work: It passed through three phases: The interventional program