Process evaluation and challenges of implementation of a school-based waterpipe tobacco smoking prevention program for teens in Lebanon

Abstract

INTRODUCTION Waterpipe tobacco smoking is increasing globally particularly among youth. In Lebanon, the high prevalence of waterpipe tobacco smoking among younger age groups calls for immediate intervention particularly given its negative health effects. To date, such interventions have rarely been implemented or evaluated. METHODS This manuscript describes the process evaluation of a school-based intervention to prevent/delay waterpipe tobacco smoking among 6th and 7th graders (n=844) in Lebanon. Process evaluation documents whether an intervention is implemented as planned, and guides understanding of the relationship between the intervention activities and outcomes. The intervention was carried out over 5 months during 2011-2012 on school premises and during school hours, using a participatory approach. The ten intervention sessions included knowledge, skills and a social promise. The process evaluation assessed fidelity, dose delivered, dose received, reach, satisfaction, and the influence of context. Tools included observation and satisfaction forms, attendance log sheets, focus group discussions, and daily journal entries. RESULTS The majority of participants (87.2%) attended at least 75% of the sessions. Results indicate high fidelity of implementation; 72.3% of the activities were rated by facilitators to be fully implemented -with high participant satisfaction; 89.5% of children chose a happy face to express their rating of the session. Facilitators rated children's participation as 'positive and active' in 77.9% of the sessions. CONCLUSIONS Main challenges to implementation were contextual at the country and school level, and related to local pro social norms around waterpipe tobacco smoking. The experience of this intervention confirms the critical importance of context in program implementation.

Application of social cognitive theory to prevent waterpipe use in male high-school students in Kerman, Iran

“…Environmental factors such as easy and inexpensive access, tobacco flavoring, and the numerous WP lounges in the city make the role of the environment more and more important, which is in line with the previous studies. [183435] Furthermore, the WP lounges in our country are attractive to students, and WP smoking venues represent a gathering place. [3637] Indeed, to change the environment requires intersectional collaboration and general policy at the macro level.…”

A Randomized Controlled Trial of a Theory-Informed School-Based Intervention to Prevent Waterpipe Tobacco Smoking: Changes in Knowledge, Attitude, and Behaviors in 6th and 7th Graders in Lebanon

“…Despite a policy prohibiting smoking in schools, many schools allow smoking on their premises. We have described these contextual challenges to this intervention more fully previously [ 52 ]. All the above contextual factors make efforts to effectively message around tobacco prevention and control difficult; and suggest that we may not have found changes in behavior even with a follow-up assessment.…”

“…The ten sessions of the intervention were organized as follows: four sessions were knowledge-based, and the other six were skill-based, including: media critical analysis, decision-making skills, refusal skills and social promise. More information on the intervention can be found elsewhere [ 52 ].…”

Implementing lung health interventions in low- and middle-income countries: a FRESH AIR systematic review and meta-synthesis

“…The studies resulting from our search were conducted in 17 different LMICs across five geographical regions: Latin America (Brazil [51][52][53][54][55], the Dominican Republic [56], Mexico [57], Surinam [58]), Africa (Malawi [59], South Africa [60][61][62]), the Middle East (Lebanon [63], Syria [64]), Asia (China [65][66][67][68][69], India [49,50,[70][71][72][73][74][75], Indonesia [73,76], Malaysia [77], Nepal [78,79], Pakistan [80], Russia [81], Thailand [82][83]) and Oceania (Fiji [85]) (table 1 and figure 3). Most studies were based in healthcare settings (n=17; primary care (n=9), secondary care (n=5), primary/secondary care combined (n=3)), followed by schools (n=13), and the community (n=6).…”

“…The fifth critical factor, "Resource availability", can be particularly challenging to address. One included study reported that workshop facilitators overcame the barrier of transportation costs by ride sharing and delivering several sessions per visit to reduce the number of visits [63]. Reducing the impact of the lack of resources generally requires innovative system strengthening [16].…”