Evaluation of the Smokeless Tobacco Awareness, Attitude, and Response Knowledge (STAARK) Scale With Integrated Risk Assessment for Tailored Intervention

Abstract

Background Smokeless tobacco (SLT) use, particularly gutkha, is prevalent in India, with cultural acceptance contributing to widespread use, especially among tribal populations. Despite awareness programs, there is limited assessment of their effectiveness, leading to continued vulnerability, even among educated groups. This study aims to evaluate public health strategies by developing and validating the SLT Awareness, Attitude, and Response Knowledge (STAARK) scale, which assesses knowledge and attitudes post-awareness programs on SLT usage through questionnaires, identifying vulnerable individuals, and enabling targeted interventions to reduce SLT use and associated health risks, particularly through integrated risk assessment (IRA). Methods This study was performed during an SLT awareness program in Nagaland, utilizing a comprehensive survey to assess participants’ demographics, knowledge, and attitudes. The STAARK score was calculated by combining normalized attitude and knowledge scores, ranging from 0 to 10, categorizing participants’ comprehension and attitudes toward SLT usage awareness. The obtained scores were assessed twice for consistency evaluation of the scale, and vulnerable individuals were subjected to IRA for targeted intervention recommendations. Reliability and correlation analyses were performed, with Cronbach’s alpha validating the scale’s internal consistency. Results About 182 participants took up the assessment, with only 180 completing the survey among the population attending the awareness program. Demographic data revealed a diverse participant group, with ages ranging from 13 to 42 years. The survey assessed participants' knowledge and attitudes toward SLT, scoring them on a 0-10 scale for knowledge and a 10-60 scale for attitude. The STAARK scale was developed to combine these scores, providing a comprehensive measure of participants' understanding and attitudes toward SLT. The mean STAARK score was 5.27 with an observed lower limit of 2.40 and an upper limit of 6.50 in the responded population. Reliability testing using Cronbach's alpha showed acceptable internal consistency, though attitude had a weaker correlation with the overall STAARK score compared to knowledge. In a follow-up assessment with 88 participants, the STAARK score averaged 5.10, reinforcing the initial findings. The risk assessment of 17 participants with STAARK scores above six identified varying levels of risk, with most falling into the low- or moderate-risk categories. The study highlights the importance of targeted interventions to address SLT usage, particularly in populations with lenient attitudes toward its consumption. Conclusions The STAARK scale can serve as a key tool for evaluating SLT awareness programs by assessing participants’ knowledge and attitudes and identifying high-risk individuals requiring personalized interventions for SLT usage cessation. It standardizes the assessment, enabling comparison across groups an...