菸害防制多元介入計畫對於偏遠地區國小學童之成效

Effectiveness of Smoking Prevention Multicomponent Intervention for Elementary School Students in a Rural Area

10.6209/JORIES.202112_66(4).0007

黃素妃(Su-Fei Huang)；許伊婷(Yi-Ting Hsu)；廖容瑜(Jung-Yu Liao)

多元介入方案 ； 偏遠地區學童 ； 菸害防制 ； 整合性行為理論 ； multicomponent intervention ； rural area elementary school students ； smoking prevention program ； integrated behavior change model

教育科學研究期刊

66卷4期（2021 / 12 / 01）

183 - 215

繁體中文

保護學童避免菸害是公共衛生重要課題，菸害防制教育應盡早施行。本研究依據整合性行為理論設計多元介入方式並評值對國小學童之改善情形。以準實驗研究設計之實驗組對照組前、後測設計，選取臺灣北部偏遠地區八所國小三到六年級學童為研究對象，四所學校為實驗組進行菸害防制介入計畫，另四所學校為對照組持續常規活動。兩組皆於介入前完成前測問卷，介入為期6個月，介入後同步進行後測，於6個月後再追蹤。本研究結果顯示，510位參與學童中，有64.5%學童暴露於二手菸環境；本介入計畫在「菸害知識」、「不吸菸的行為意圖」、「拒吸二手菸自我效能」於控制前測得分的前提下，實驗組顯著較對照組表現良好。本研究支持以整合性行為理論所發展的菸害防制介入計畫具有部分成效，此一整合學生、學校家庭與社區的多元介入方式，有助於作為未來公共衛生推動者菸害防制規劃之參考。

1. Both smoking and exposure to secondhand smoke (SHS) are associated with short-term and long-term health hazards. Protecting school students from smoking and SHS exposure is a key public health topic. Smoking prevention education should be introduced as early as possible to address smoking among students. Studies have suggested that implementing smoking prevention education in elementary schools can be an effective instrument for preventing smoking onset in adolescence. The integrated behavior change model (I-Change Model) is a well-known framework for preventing smoking among youths and adolescents. This model comprises attitude, social influences (comprising norms, modeling, and pressure) and self-efficacy. Although numerous European countries have used this model to implement smoke-free prevention programs, it has not yet been applied in Taiwan. Moreover, smoking prevention programs are lacking at the elementary school level in Taiwan and other countries, especially in rural areas. Therefore, we developed a multicomponent intervention based on the I-Change Model and evaluated its effect on elementary school students in a rural area. 2. In this quasiexperimental study, we applied a repeated-measurement design for the comparison and experimental groups. Students in grades 3 to 6 from four elementary schools in rural Southern Taiwan were enrolled as participants in the experimental group. Students for the comparison group were recruited from four other schools from the same area with similar school type and size as the schools selected for the experiment. In total, the 190 participants in the experimental group underwent a 6-month smoking prevention intervention program, whereas the 330 participants in the comparison group received routine health education. The multicomponent intervention, which was based on the I-Change Model, was focused on smoking and SHS prevention. We applied intervention strategies at the individual, family, school, and community levels. At the individual level, a six-session program (with each session being 45 min) named ＂Smoke-Free Co.＂ was implemented. At the school level, the strategies applied included a teacher empowerment workshop and a smoke-free campus program and policy. At the family level, the participants' parents received a letter on the implementation of a smoke-free environment and smoke prevention worksheets through parent-teacher contact books. At the community level, social media were used to deliver information regarding the implementation of smoke- free environments. Preintervention and postintervention measurements for both groups were conducted through a structured questionnaire. During the 6-month follow-up after the end of the intervention, a third set of responses was obtained from both groups synchronously. Three sets of responses were obtained from 169 and 161 participants from the experimental and comparison groups, respectively. 3. In the present study, almost all the participants (94%) did not smoke, and 64.5% were exposed to SHS. The generalized estimating equation results revealed significant group-related and time-related interactions for knowledge, behavioral intention not to smoke, and SHS resistance self-efficacy. Compared with the comparison group and their baseline scores, the experimental group achieved significantly higher scores for knowledge at the end of the intervention (β = 0.65, p ＜ 0.001) and at the 6-month follow-up after the end of the intervention (β = 0.41, p = .027). For behavioral intention not to smoke, the participants in the experimental group achieved significantly higher scores relative to the participants in the comparison group at the 6-month follow-up after the end of the intervention (β = 0.50, p = 0.045). For SHS refusal self-efficacy, the participants in the experimental group had significantly higher scores relative to the participants in the comparison group at the end of the intervention (β = 4.55, p = 0.010). No significant difference was observed for pros and cons, social norms, social modeling, social pressure, smoking resistance self-efficacy, intention to smoke, SHS exposure, and intention to avoid SHS exposure. 4. In summary, the I-Change Model-based multicomponent intervention (comprising multiple strategy levels) influenced knowledge, behavioral intention not to smoke, and SHS refusal self-efficacy among elementary school students in rural Southern Taiwan. Our results partially correspond to those of other studies that examined the I-Change Model. This slight disparity may be attributed to the cultural differences between different countries and the varying levels of proactivity among teachers. Moreover, during the study period of the present study, some participants graduated from elementary school and progressed to junior high school, and this transition could have reduced the effects of the intervention. Therefore, the program must incorporate other effective strategies to enhance its effectiveness. This study has several limitations. First, selection bias may have influenced the results; however, generalized estimating equations were used after controlling for differences in demographic variables among the two groups to address the aforementioned concern. Second, the lower retention rate of our comparison group could also have affected the results. Third, the collected self-reported data could have caused measurement errors because of social expectations. To eliminate the effects of this bias, we collected anonymous data and instructed the participants to complete the questionnaire on the basis of their actual situation. 5. The current findings suggest that, for children who do not smoke but are exposed to SHS, the I-Change Model-based smoking prevention intervention was partially effective in influencing knowledge, behavioral intention not to smoke, and SHS refusal self-efficacy. This program was appropriately applied to students in grades 3 to 6 in rural Southern Taiwan. Our results relating to the integration of multiple intervention methods (for students, schools, families, and communities) can serve as a reference for public health practitioners with respect to prevention planning. In the future, the effectiveness of interventions involving smoking prevention programs must be enhanced by increasing their implementation intensity and utilizing social media. Furthermore, these measures can act as a booster program with a protective factor that helps student to cope with the pressure of school life and confront challenges when they progress to junior high school.

1. 許原榕、楊振宇、嚴雅音、陳志章、陳富莉、蔡文玲、林碧莉、林雅瑩、柯惠玲、黃曉靈（2010）。屏東縣國小學童菸害知識，態度，社會環境因素與吸菸行為之相關探討。臺灣口腔醫學科學雜誌，26（2），106-119。【Hsu, Y.-J., Yang, C.-Y., Yen, Y.-Y., Chen, C.-C., Chen, F.-L., Tsai, W.-L., Lin, P.-L., Lin, Y.-Y., Ko, H.-L., & Huang, H.-L. (2010). Knowledge, attitude, social environmental factors associated with smoking behavior among primary schoolchildren in Pin-Tung county. Taiwan Journal of Oral Medicine Sciences, 26(2), 106-119. 】
   連結：
2. 廖信榮、李景美、林世華、苗迺芳、龍芝寧、李淑卿、林宜蕙、顏麗娟、周怡汝（2013）。臺北市國中學生菸害預防教育介入成效研究。學校衛生，63，25-47。https://doi.org/10. 30026/CJSH.201312_(63).0002【Liao, H.-J., Lee, C.-M., Lin, S.-H., Miao, N.-F., Lung, C.-N., Lee, S.-C., Li, Y.-H., Yen, L.-C., & Chou, Y.-R. (2013). Study on the effects of a smoking prevention program among the junior high school students in Taipei City. Chinese Journal of School Health, 63, 25-47. 】
   連結：
3. Akhtar, P. C., Haw, S. J., Currie, D. B., Zachary, R., & Currie, C. E. (2009). Smoking restrictions in the home and secondhand smoke exposure among primary schoolchildren before and after introduction of the Scottish smoke-free legislation. Tobacco Control, 18(5), 409-415. https://doi. org/10.1136/tc.2009.030627
   連結：
4. Ali, M. M., & Dwyer, D. S. (2009). Estimating peer effects in adolescent smoking behavior: A longitudinal analysis. Journal of Adolescent Health, 45(4), 402-408.
   連結：
5. Andrews, J. A., Gordon, J. S., Hampson, S. H., Gunn, B., Christiansen, S. M., & Slovic, P. (2013). Long-term efficacy of Click City®: Tobacco: A school-based tobacco prevention program. Nicotine & Tobacco Research, 16(1), 33-41.
   連結：
6. Ariza, C., Nebot, M., Tomás, Z., Giménez, E., Valmayor, S., Tarilonte, V., & De Vries, H. (2008). Longitudinal effects of the European smoking prevention framework approach (ESFA) project in Spanish adolescents. European Journal of Public Health, 18(5), 491-497.
   連結：
7. Ausems, M., Mesters, I., Van Breukelen, G., & De Vries, H. (2009). Smoking among Dutch elementary schoolchildren: Gender-specific predictors. Health Education Research, 24(5), 818-　828.
   連結：
8. Bast, L. S., Andersen, A., Ersbøll, A. K., & Due, P. (2019). Implementation fidelity and adolescent smoking: The X: IT study— A school randomized smoking prevention trial. Evaluation and Program Planning, 72, 24-32.
   連結：
9. Borzekowski, D. L. (2009). Considering children and health literacy: A theoretical approach. Pediatrics, 124, S282-8.
   連結：
10. Côté, F., Godin, G., & Gagné, C. (2006). Efficiency of an evidence-based intervention to promote and reinforce tobacco abstinence among elementary schoolchildren in a school transition period. Health Education & Behavior, 33(6), 747-759.
    連結：
11. Chang, F.-C., Lee, C.-M., Lai, H.-R., Chiang, J.-T., Lee, P.-H., & Chen, W.-J. (2006). Social influences and self-efficacy as predictors of youth smoking initiation and cessation: A 3-year longitudinal study of vocational high school students in Taiwan. Addiction, 101(11), 1645-1655.
    連結：
12. Chang, H.-Y., Wu, W.-C., Wu, C.-C., Cheng, J. Y., Hurng, B.-S., & Yen, L.-L. (2011). The incidence of experimental smoking in school children: An 8-year follow-up of the child and adolescent behaviors in long-term evolution (CABLE) study. BMC Public Health, 11(1), 844.
    連結：
13. Conrad, K. M., Flay, B. R., & Hill, D. (1992). Why children start smoking cigarettes: Predictors of onset. Addiction, 87(12), 1711-1724.
    連結：
14. Cremers, H.-P., Mercken, L., Candel, M., de Vries, H., & Oenema, A. (2015). A web-based, computer-tailored smoking prevention program to prevent children from starting to smoke after transferring to secondary school: Randomized controlled trial. Journal of Medical Internet Research, 17(3), e59.
    連結：
15. Cremers, H.-P., Mercken, L., Oenema, A., & de Vries, H. (2012). A web-based computer-tailored smoking prevention programme for primary school children: Intervention design and study protocol. BMC Public Health, 12, 277.
    連結：
16. Crone, M. R., Spruijt, R., Dijkstra, N., Willemsen, M. C., & Paulussen, T. G. W. M. (2011). Does a smoking prevention program in elementary schools prepare children for secondary school? Preventive Medicine, 52(1), 53-59.
    連結：
17. De Vries, H., Dijk, F., Wetzels, J., Mudde, A., Kremers, S., Ariza, C., Vitória, P. D., Fielder, A., Holm, K., Janssen, K., Lehtovuori, R., & Candel, M. (2005). The European smoking prevention framework approach (ESFA): Effects after 24 and 30 months. Health Education Research, 21(1), 116-132.
    連結：
18. De Vries, H., Mesters, I., Van de Steeg, H., & Honing, C. (2005). The general public’s information needs and perceptions regarding hereditary cancer: An application of the Integrated Change Model. Patient Education and Counseling, 56(2), 154-165.
    連結：
19. De Vries, H., & Mudde, A. N. (1998). Predicting stage transitions for smoking cessation applying the attitude-social influence-efficacy model. Psychology and Health, 13(2), 369-385.
    連結：
20. De Vries, H., Mudde, A., Kremers, S., Wetzels, J., Uiters, E., Ariza, C., Vitória, P. D., Fielder, A., Holm, K., Janssen, K., Lehtovuori, R., & Candel, M. (2003). The European smoking prevention framework approach (ESFA): Short-term effects. Health Education Research, 18(6), 649-663.
    連結：
21. De Vries, H., Mudde, A., Leijs, I., Charlton, A., Vartiainen, E., Buijs, G., Clemente, M. P., Storm, H., Navarro, A. G., Nebot, M., Prins, T., & Kremers, S. (2003). The European smoking prevention framework approach (EFSA): An example of integral prevention. Health Education Research, 18(5), 611-626.
    連結：
22. Dijkstra, M., Mesters, I., De Vries, H., Van Breukelen, G., & Parcel, G. S. (1999). Effectiveness of a social influence approach and boosters to smoking prevention. Health Education Research, 14(6), 791-802.
    連結：
23. Dobbins, M., DeCorby, K., Manske, S., & Goldblatt, E. (2008). Effective practices for school-based tobacco use prevention. Preventive Medicine, 46(4), 289-297.
    連結：
24. Dolcini, M. M., Adler, N. E., Lee, P., & Bauman, K. E. (2003). An assessment of the validity of adolescent self-reported smoking using three biological indicators. Nicotine & Tobacco Research, 5(4), 473-483.
    連結：
25. Eiser, J. R., Morgan, M., Gammage, P., & Gray, E. (1989). Adolescent smoking: Attitudes, norms and parental influence. British Journal of Social Psychology, 28(3), 193-202.
    連結：
26. Gervais, A., O’loughlin, J., Meshefedjian, G., Bancej, C., & Tremblay, M. (2006). Milestones in the natural course of onset of cigarette use among adolescents. Canadian Medical Association Journal, 175(3), 255-261.
    連結：
27. Glynn, T. J. (1993). Improving the health of United States children: The need for early interventions in tobacco use. Preventive Medicine, 22(4), 513-519.
    連結：
28. Hampson, S. E., Andrews, J. A., & Barckley, M. (2007). Predictors of the development of elementary-school children’s intentions to smoke cigarettes: Hostility, prototypes, and subjective norms. Nicotine & Tobacco Research, 9(7), 751-760.
    連結：
29. Hanewinkel, R., Isensee, B., Sargent, J. D., & Morgenstern, M. (2011). Cigarette advertising and teen smoking initiation. Pediatrics, 127(2), e271-e278.
    連結：
30. Holliday, J. C., Moore, G. F., & Moore, L. A. (2009). Changes in child exposure to secondhand smoke after implementation of smoke-free legislation in Wales: A repeated cross-sectional study. BMC Public Health, 9(1), 430.
    連結：
31. Huang, H.-L., Chen, T., Chen, F.-L., Magnus, J., Rice, J., Yen, Y.-Y., & Hsu, C. C. (2009). A study of smoking disparity and factors associated with children smoking behavior in the mountain and city schools in Taiwan. Journal of School Health, 79(2), 67-73. https://doi.org/10.1111/j.1746-　1561.2008.00378.x
    連結：
32. Huque, R., Dogar, O., Cameron, I., Thomson, H., Amos, A., & Siddiqi, K. (2015). Children learning about second-hand smoking: A feasibility cluster randomized controlled trial. Nicotine & Tobacco Research, 17(12), 1465-1472.
    連結：
33. Hwang, M. S., Yeagley, K. L., & Petosa, R. (2004). A meta-analysis of adolescent psychosocial smoking prevention programs published between 1978 and 1997 in the United States. Health Education & Behavior, 31(6), 702-719.
    連結：
34. Isensee, B., & Hanewinkel, R. (2012). Meta-analysis on the effects of the smoke-free class competition on smoking prevention in adolescents. European Addiction Research, 18(3), 110-　115.
    連結：
35. Isensee, B., Hansen, J., Maruska, K., & Hanewinkel, R. (2014). Effects of a school-based prevention programme on smoking in early adolescence: A 6-month follow-up of the “Eigenständig warden” cluster randomised trial. BMJ Open, 4(1), e004422.
    連結：
36. Kobus, K. (2003). Peers and adolescent smoking. Addiction, 98(s1), 37-55.
    連結：
37. Lotrean, L. M., Dijk, F., Mesters, I., Ionut, C., & De Vries, H. (2010). Evaluation of a peer-led smoking prevention programme for Romanian adolescents. Health Education Research, 25(5), 803-814.
    連結：
38. Lund, L., Lauemøller, S. G., Kjeld, S. G., Andersen, A., & Bast, L. S. (2020). Gender differences in attitudes towards a school-based smoking prevention intervention. Scandinavian Journal of Public Health, 49(5), 511-518.
    連結：
39. McGee, C. E., Trigwell, J., Fairclough, S. J., Murphy, R. C., Porcellato, L., Ussher, M., & Foweather, L. (2016). Effect of a sport-for-health intervention (SmokeFree Sports) on smoking-related intentions and cognitions among 9-10 year old primary school children: A controlled trial. BMC Public Health, 16(1), 445.
    連結：
40. Nurumal, M. S., Zain, S. H. M., Mohamed, M. H. N., & Shorey, S. (2021). Effectiveness of school-based smoking prevention education program (SPEP) among nonsmoking adolescents: A quasi-experimental study. Journal of School Nursing, 37(5), 333-342.
    連結：
41. Passey, M. E., Longman, J. M., Robinson, J., Wiggers, J., & Jones, L. L. (2016). Smoke-free homes: What are the barriers, motivators and enablers? A qualitative systematic review and thematic synthesis. BMJ Open, 6(3), e010260.
    連結：
42. Rosen, L. J., Noach, M. B., Winickoff, J. P., & Hovell, M. F. (2012). Parental smoking cessation to protect young children: A systematic review and meta-analysis. Pediatrics, 129(1), 141-152.
    連結：
43. Saulyte, J., Regueira, C., Montes-Martínez, A., Khudyakov, P., & Takkouche, B. (2014). Active or passive exposure to tobacco smoking and allergic rhinitis, allergic dermatitis, and food allergy in adults and children: A systematic review and meta-analysis. PLoS Medicine, 11(3), e1001611.
    連結：
44. Simons-Morton, B. G., & Farhat, T. (2010). Recent findings on peer group influences on adolescent smoking. Journal of Primary Prevention, 31(4), 191-208.
    連結：
45. Taylor, K. A., Sharma, E., Edwards, K. C., Halenar, M. J., Kissin, W., Kasza, K. A., Day, H., Anic, G. Gardner, L. D. Hammad, H. T., Hull, L. C., Bansal-Travers, M., Limpert, J., Borek, N., Kimmel, H. L., Compton, W. M., Hyldnd, A., & Stanton, C. (2020). Longitudinal pathways of exclusive and polytobacco cigarette use among youth, young adults and adults in the USA: Findings from the PATH Study Waves 1-3 (2013-2016). Tobacco Control, 29(Suppl 3), s139-s146.
    連結：
46. Thomas, R. E., McLellan, J., & Perera, R. (2013). School-based programmes for preventing smoking. Evidence-Based Child Health: A Cochrane Review Journal, 8(5), 1616-2040.
    連結：
47. Thomas, R. E., McLellan, J., & Perera, R. (2015). Effectiveness of school-based smoking prevention curricula: Systematic review and meta-analysis. BMJ Open, 5(3), e006976.
    連結：
48. Vallata, A., O’Loughlin, J., Cengelli, S., & Alla, F. (2021). Predictors of cigarette smoking cessation in adolescents: A systematic review. Journal of Adolescent Health, 68(4), 649-657.
    連結：
49. Wiborg, G., & Hanewinkel, R. (2002). Effectiveness of the “smoke-free class competition” in delaying the onset of smoking in adolescence. Preventive Medicine, 35(3), 241-249.
    連結：
50. Wiehe, S. E., Garrison, M. M., Christakis, D. A., Ebel, B. E., & Rivara, F. P. (2005). A systematic review of school-based smoking prevention trials with long-term follow-up. Journal of Adolescent Health, 36(3), 162-169.
    連結：
51. Wilkinson, A. V., Shete, S., & Prokhorov, A. V. (2008). The moderating role of parental smoking on their children’s attitudes toward smoking among a predominantly minority sample: A cross-sectional analysis. Substance Abuse Treatment, Prevention, and Policy, 3(1), 18.
    連結：
52. Bach, L. (2017). The path to tobacco addiction starts at very young ages. Campaign for Tobacco Free Kids. https://www.tobaccofreekids.org/assets/factsheets/0127.pdf
53. Control, C. f. D., & Prevention. (1994). Guidelines for school health programs to prevent tobacco use and addiction. Morbidity and Mortality Weekly Report, 43(RR-2), 1-24.
54. Ferrante, M., Fiore, M., Leon, L., Costantidines, F., Castaing, M., Fallico, R., Sciacca, S., & Modonutti, G. B. (2010). Age of smoking initiation, tobacco habits and risk perception among primary, middle and high school students in southern Italy. Italian Journal of Public Health, 7(3), 262-267.
55. Office of the Surgeon General. (2012). Preventing tobacco use among youth and young adults: A report of the Surgeon General. Centers for Disease Control and Prevention (US).
56. Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17-5044, NSDUH Series H-52). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/