Diakonia-ammattikorkeakoulu B REPORTS 55 Noppari (toim.) Monialaiset verkostot perheitä tukemassa Sakari Kainulainen & Sami Kivelä (eds.) I Will Never Smoke! Results of Anti-tobacco Teaching and Intervention in Schools in Nepal Sakari Kainulainen & Sami Kivelä I Will Never Smoke! Results of Anti-tobacco Teaching and Intervention in Schools in Nepal Diakonia-ammattikorkeakoulu Diaconia University of Applied Sciences Helsinki 2012 1 DIAKONIA-AMMATTIKORKEAKOULUN JULKAISUJA B Raportteja 55 B Reports 55 Julkaisija: Diakonia-ammattikorkeakoulu Publisher: Diaconia University of Applied Sciences Photo on the cover: Sami Kivelä Lay out: Tiina Hallenberg ISBN 978-952-493-178-6 (print) ISBN 978-952-493-179-3 (pdf) ISSN: 1455-9927 2., uudistettu painos Juvenes Print Oy Tampere 2012 2 ABSTRACT Kainulainen Sakari I Will Never Smoke! Kivelä Sami (eds.) Results of Anti-tobacco Teaching and Intervention in Schools in Nepal Helsinki : Diakonia-ammattikorkeakoulu, 2012 Diaconia University of Applied Sciences, 2012 126 p. Diakonia-ammattikorkeakoulun julkaisuja B Reports 55 ISBN ISSN 978-952-493-178-6 (printed) 1455-9927 978-952-493-179-3 (pdf) Tobacco use is a major risk factor behind non-communicable diseases and premature deaths. Health education is one way to decrease the prevalen- ce of non-communicable diseases, and school-level interventions have yiel- ded promising results in various countries. Health Education and Tobacco Intervention Program (HETIP) has been carried out in Nepal in 2001–2012. The nationwide project has reached hundreds of public schools and hun- dreds of thousands of people in two thirds of all the 75 districts in Nepal. It has been organized by Scheer Memorial Hospital of Seventh-day Adventists in Banepa, Kavre, with the help of ETRA Association in Finland. The project has been largely funded by the Ministry for Foreign Affairs in Finland. The present publication discusses tobacco use in Nepal and evaluates the out- come of the project. After the introduction by Sami Kivelä the first article written by Heikki Hiilamo presents the strategies of the global tobacco industry and key me- asures and challenges for tobacco control in Nepal. The second article by Radha Devi Bangdel gives an overview of the health situation in Nepal and recent developments in health policy. Aune Greggas then reveals the histo- ry, context and statistics of the Health Education and Tobacco Intervention Program, followed by Sundar Thapa’s article on the actual implementation and working methods of the program. The concluding two articles present the project evaluation carried out by Sami Kivelä and Sakari Kainulainen at Diaconia University of Applied Sciences in Finland. The evaluation consists of qualitative and quantitative data. 3 An intensive course for higher education students was held in Nepal in 2011 as a means for project evaluation. Over 30 Nepalese community schools were visited in the Central Development Region, and extensive data were collected by an international team of researchers and assistants, to be supplemented with later data from the Terai region. A VIP seminar was held in 2012 to en- hance the capacity of policy makers in tobacco control. The results show that the HETIP intervention has succeeded as a preventive tool and in helping to give up the use of tobacco. Secondary school students as well as staff members have often found the program personally benefi- cial. Furthermore, it has created positive attitudes in the community and in some cases shaped the curriculum. It may be worthwhile to consider separa- te anti-tobacco programs for male and female students in the future. As such the HETIP program has been competent and efficient in complementing the promotive and preventive health education given by various interest groups in Nepal. Keywords: Anti-tobacco work; Health education; Intervention; Nepal; Secondary education; Smoking; Tobacco use Available: Printed and Open Access Order: http://granum.ta.fi/ Open acces: http://www.diak.fi/tyoelama/Julkaisut/B-sarjan%20julkaisut/Sivut/default. aspx 4 Contents ABSTRACT 3 Sami Kivelä Evaluating an anti-tobacco intervention 9 Aim of the report 9 Building a partnership for education and evaluation 10 Structure of the publication 11 Intensive course as part of the evaluation process 13 Acknowledgements 15 References 17 Heikki Hiilamo Tobacco control in Nepal 19 Introduction 19 Tobacco industry’s global strategies 20 Smoking prevalence in Nepal 23 Early tobacco control measures 25 Implementing FTCT in Nepal 26 Tobacco Control and Regulation Act 27 Key holders in tobacco control 27 Future challenges 29 References 29 Radha Devi Bangdel Health in Nepal 33 Introduction 33 Child health 35 Family health 37 Diseases 39 Morbidity 41 Mortality 42 Policy development 45 National Health Policy, 1991 46 Second Long Term Health Plan, 1997-2017 47 Conclusion 51 References 52 5 Aune Greggas School Level Health Education and Tobacco Intervention Program (HETIP) in Nepal by ETRA Association, Finland 53 Background of HETIP program 53 Lessons learned in Finland - effects of anti-smoking programs in Finnish schools 54 School Level Health Education and Tobacco Intervention Program in Nepal 56 Previous Findings on Youth Smoking in Nepal 57 Global Youth Tobacco Survey GYTS 57 Pokhara Submetropolitan City Study 59 Manipal College study in 2010 60 The outputs of HETIP program 60 References 63 Sundar Thapa Working methods of School Level Health Education and Tobacco Intervention Program in Nepal 2001–2012 71 Background 71 Phase 1: School Level Health Education and Smoking Intervention 72 Phase 2: School Level Health Education and Tobacco Intervention 73 Phase 3: School Level Health Education and Tobacco Intervention continued 74 Phase 4: School Level Health Education and Tobacco Intervention continued & Evaluation 75 Program Participation 76 Training of Trainers (TOT) and Refreshing Training (RT) 76 Orientation / Review / Closing Program 76 Press Conference 77 Electronic Media 77 Program Implementation 78 Conclusions 80 Sami Kivelä Constructing non-smoking areas for school children 83 Introduction 83 Background information 86 Outline of secondary education in Nepal 86 Recruitment and working conditions of teachers 87 Notes on culture, ethnicity and religion 89 6 Empirical findings 89 Description of the interviewees 89 General attitudes and actions towards health and the use of tobacco 90 Findings on the curriculum and other pedagogical tools 94 Observations on the school environment 98 Conclusion 102 References 104 Sakari Kainulainen Use of tobacco products among Nepalese school children and effects of preventive project work 107 Introduction and aim of the article 107 Data and methods 108 Results 111 Prevalence of tobacco product use in different regions and grades 111 Lasting effects of preventive work 114 Results of HETIP intervention 119 Discussion 121 References 122 WRITERS 125 7 8 Sami Kivelä Evaluating an anti-tobacco intervention Aim of the report he Health Education & Tobacco Intervention Program (HETIP) has been Tcarried out in Nepal during 2001-2012. The aim of the program has been to raise awareness of smoking-related health hazards in Nepalese schools (HETIP evaluation plan 2010). HETIP has been carried out as a project largely funded by the Ministry for Foreign Affairs in Finland, and the present publi- cation will discuss and evaluate the outcome of the project. The external evaluation team consists of staff members at Diaconia University of Applied Sciences, Finland. The team has worked in cooperation with HETIP project members, especially the project secretary, Aune Greggas, who has provided essential background information and necessary contacts to Nepal. The HETIP team itself has been active in recording, systemizing and evaluating their activities during the years, and the evaluation team has benefited from this information. However, the team has maintained its im- partiality as an external actor in its choices and assessments. Instead of a full-scale project evaluation this publication is a review of the results of the program. Nevertheless the articles have been constructed kee- ping in mind the requirements of the Ministry for Foreign Affairs in Finland. The ministry follows evaluation guidelines set by OECD’s Development Assistance Committee (DAC) and its Expert Group on Aid Evaluation (GPDME 2007, 39). According to OECD/DAC, […] an evaluation is an assessment, as systematic and objective as possible, of an on-going or completed project, programme or policy, its design, implementation and results. The aim is to determine the relevance and fulfillment of objectives, developmental efficiency, effectiveness, impact and sustainability. DAC also emphasizes the impartiality of the evaluation process. The provi- ded information needs to be useful and credible, and the evaluation should yield results that can be incorporated in the decision-making process of part- ner countries as well as donors. This report acknowledges the following perspectives regarding the HETIP project: • Relevance: Does the project make sense within the context of its environment? • Impact: What has happened (or is likely to happen) as a consequence of the project? 9 • Effectiveness: To what extent has (or is likely to be) the project purpose been achieved, and to what extent is the achievement the result of the project? • Efficiency: Does the quantity and quality of the results of the project justify the quantity and quality of the means used for achieving them? • Sustainability: What has happened (or is likely