Critically compare a Behavioural Change approach with a

comprehensive and integrative (Ecological Public Health) in

smoking behaviour for adolescents in Indonesia.

Name of Student: Ridwan Amiruddin

Course : 7880 Health Determinants and Global
Response
 Critically compare a Behavioural Change approach with a
comprehensive and integrative (Ecological Public Health) in
smoking behaviour for adolescents in Indonesia.

Introduction

This article critically compares a behavioural change approach with a

comprehensive and integrative model in smoking behaviour for adolescents in
Indonesia. Focus discussion provides implication of behavioural change
approach and ecological public health approach to analyse behavioural smoking
for adolescents.
Tobacco use is a major public health problem in all countries. In the United
States of America, tobacco use is the single leading preventable cause of death,
accounting for approximately 430,000 deaths each year (WHO, 2008). As was
documented extensively in previous Surgeon General’s reports, cigarette
smoking has been causally linked to lung cancer and other fatal malignancies,
atherosclerosis and coronary heart disease, chronic obstructive pulmonary
disease, and other conditions that constitute a wide array of serious health
consequences. More recent studies have concluded that passive (or involuntary)
smoking can cause disease, including lung cancer, in healthy non-smokers.
In Indonesia smoking prevalence among adults increased to 31.5% in 2001
from 26.9% in 1995 (MOH, 2008). In 2001, 62.2% of adult males smoked,
compared with 53.4% in 1995. Only 1.3% women reported smoking regularly in
2001. Prevalence according by age group increases rapidly after 10 to 14 years
of age among males: from 0.7% (1995) to 24.2% (2001) (MOH, 2008).
Among youth ages 10 to 14 years old, the majority of those who ever use of
tobacco were boys (about 92 percent). For both boys and girls, the highest
proportion of ever use of tobacco was among those with age of 13 years old
(about 41 percent) and followed by those with the age of 14 years old (about 23

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percent). It seems that boys have experience in using of tobacco in earlier ages
(10 and 11 years old) compared to girls (12 years old). The experience of youth
tobacco use was dominantly among those who living in urban area (about 79
percent). Meanwhile, the major percentage of the youth tobacco use was in the

level education of primary/middle school, followed  by  those with level education 

of high school and illiterate (CHRUI, 2001).
Risk factors for smoking initiation, surveys of current adult smokers reveal
that almost 80% began smoking at 16 years of age or earlier (Jaen, 2000).
Initiation of cigarette smoking is associated with multiple factors. Environmental
factors include availability of cigarettes, the perception that tobacco use is the
norm, peer and sibling attitudes, and lack of parental support during
adolescence. Behavioural factors include low academic achievement,
rebelliousness, alienation from school and lack of skill to resist offers of
cigarettes. Personal factors include low self esteem and belief that smoking
confers future advantages in social life. Others factors associated with initiation
of smoking include price of cigarettes, cigarettes advertising and promotions, and
degree of exposure to affective counter advertising and school-based prevention
program.

Behavioural Change Model

Behaviour change theories and models from the social and behavioural
sciences explain the biological, cognitive, behavioural, and psychosocial/
environmental determinants of health-related behaviours. Thus they also define
interventions to produce changes in knowledge, attitudes, motivations, self-
confidence, skills, and social supports required for behaviour change and
maintenance (Whitlock, at. al, 2002). The application of relevant theoretical
models to behavioural interventions is an important contribution to strengthening
health program, especially to reduce tobacco use.

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 The Health Belief Model (HBM) is a psychological model that attempts to
explain and predict health behaviors by focusing on the attitudes and beliefs of
individuals.

The HBM has been adapted to explore a variety of long- and short-term
health behaviours, including sexual risk behaviors and the transmission of
HIV/AIDS and tobacco control. The key variables of the HBM are as follows
(Rosenstock, Strecher and Becker, 1994; Corcoran, 2007).

a. Perceived Threat: Consists of two parts: perceived susceptibility and

perceived severity of a health condition. E.g. tobacco use is the main risk
factors that lead to death all over the world. In 2005 was 5.4 million people
died from lung cancer, heart disease and other illness which related to
tobacco (WHO, 2008).
b. Perceived Susceptibility: One's subjective perception of the risk of
contracting a health condition.
c. Perceived Severity: Feelings concerning the seriousness of contracting an
illness or of leaving it untreated (including evaluations of both medical and
clinical consequences and possible social consequences).
d. Perceived Benefits: The believed effectiveness of strategies designed to
reduce the threat of illness.
e. Perceived Barriers: The potential negative consequences that may result
from taking particular health actions, including physical, psychological, and
financial demands.
f. Cues to Action: Events, either bodily (e.g., physical symptoms of a health
condition) or environmental (e.g., media publicity) that motivate people to
take action.
g. Other Variables: Diverse demographic, sociopsychological, and structural
variables that affect an individual's perceptions and thus indirectly
influence health-related behaviour.

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Implication Health Belief Model for Quitting smoke

The model proposes that a person’s behaviour can be predicted based on

how vulnerable the individual considers themselves to be. “Vulnerable” is
expresses in the HBM through risk (perceived susceptibility) and the seriousness
of consequences (severity). These two vulnerability variables need to be
considered before a decision can take place. This means a person has to weigh
up the cost/benefits (Naidoo and Wills 2000 cited in Corcoran, 2007) or
pros/cons of performing behaviour (Corcoran, 2007; Kerr, 2000).
The HBM includes four factors that need to take place for a behaviour
change to occur:
a. The person needs to have an ‘incentive’ to change their
behaviour, For example: An “incentive” for a person to stop
smoking could be desire not to smoke around a new baby.
b. The person must feel there is a ‘risk’ of continuing the current
behaviour.
c. The person must belief change will have ‘benefits’ and these
need to outweighs the ‘barriers`.
d. The person must have the ‘confidence’ (self-efficacy) to make the
change to their behaviour.

Thus, individual may be more likely to stop smoking if they are aware of
the health consequences and think they are vulnerable to (e.g. lung cancer).
Connected with their risk assessment is their belief in the cessation of smoking
benefiting their health and whether it will have any other benefits. However, the
individual may decide that the long term benefits of giving up smoking are not
worth the short term problems of nicotine withdrawal and missing the pleasure of
smoking. Outside forces (including the health warnings on cigarette packets) may
motivate or maintain behavioural change. The health belief model maintains that
‘cues’ to behaviour change are important. The health belief model has been most
useful when applied to relatively straightforward actions (Nutbeam, 2006). It has

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been less effective in long term, complex and socially determined behaviour
changes. Despite its limits it has proved useful in informing campaign about the
need to consider the ways in which beliefs can determine changes in behaviour
(Baum, 2008).
Smoking cessation at any age can prevent much of the future risk of
tobacco-related diseases. In 2004, an estimated 14.6 million (40.5%) adult
smokers had stopped smoking for at least 1 day because they were trying to quit;
however, about 5% are successful in quitting for at least 1 year. 37,38%
Clinicians play a critical role in encouraging smokers to quit and in providing or
referring patients to appropriate counselling and treatment (Vilma, 2006).
The essential features of smoking cessation advice by health care providers
are known as the 5 A’s: ask about tobacco use, advise to quit, assess willingness
to make a quit attempt, assist in the quit attempt, and arrange timely follow up. All
health professionals and particularly those in primary care (because of the extent
and ease of access to smokers) have a vital role in helping smokers to stop
(BHF, 2001).
The basic essentials are to:
Ask about and record smoking status, keeping the record up to date
Advise smokers of the benefits of stopping in a personalised and appropriate
way, relating this to patient concerns and any health problems where possible.
Assess motivation to stop - and reinforce if possible. Smokers are much more
likely to stop after suffering an acute event such as myocardial infarction after
which about 20% quit smoking.
Assist smokers to stop: this to include useful tips on how best to try, the offer of
support and considerations of either NRT (nicotine replacement therapy) *or
bupropion * (with accurate information and advice about these).
Arrange follow-up if possible - or review when next seen. Alternatively refer the
patient to a specialist smoking cessation service.

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Ecological Public Health Model
Ecological Public Health as an ecological framework for the development of
health policy is, in essence, an integrated approach. Focussed on prevention, its
component policies and strategic thrust aim toward developing opportunities for
health-making choices by organizations and individuals. Its policy components
would be designed to make the creation and maintenance of healthful
environments and personal habits the easiest the ‘cheapest’ and most numerous-
choices for selection by governmental units and corporations, producers and
consumers, among all the options available to them. Policies would emphasize
the aspects of environments and ways of living which have largest potential for
promoting health (Milio in Chu, 2008).
Ecological public health is an extension of the new public health with
health viewed in a holistic sense and the recognition that one’s physical, mental
and social wellbeing are determined by the interaction of environmental, socio-
economic, cultural, political and personal factors’. Public policies must rely on
health impact in terms of sustainable health for people. These policies have to
consider ‘equity, sustainability, conviviality and preservation of the global
environment’ (Chu, 1994).
Ilona Kickbusch (1989) and Chu (2007) suggested that the concept of an
ecological public health has emerged in response to a new range of health risks
associated with the global ecological issues and the social cultural and economic
patterns of our societies. Thus, the ecological public health an extension of the
new public health with health viewed in a holistic sense, and the recognition that
one’s physical , mental an social well beings are determined by the interaction of
environmental, socio economic, cultural, political and personal factors.
A key characteristic of the ecological model is the notion of connectedness
between human beings, their physical and social environment and their health.
The thrust of the action-oriented ecological public health is to integrate
environment and health through intersectoral corporation (Chu, 2008).

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Implication Ecological Public Health for smoking behaviour
Integrative program to control tobacco is motivational interventions. One
method of motivating smokers to quit is through tobacco control. This include
legislation to ban tobacco advertising and sale to young people, health
education, taxation to increase cigarettes prices, restriction of smoking in public
space, and product modification through the regulation of nicotine and tar
content (Reid 1996; Rutter, 2002).
However, another large-scale community intervention in the USA, the
community intervention trial for smoking cessation, which took place over 4 years
and involved 22 communities (half receiving a community intervention and half
acting as control), indicated no difference in the cessation rate for heavy smokers
(COMMIT, 1995; Rutter, 2002). Foulds (1999), suggested that the result might
have occurred because, in communities or countries where the health education
message for anti-smoking is accepted and motivation for quitting is already high,
motivational interventions will produce only small effects and will have a
negligible impact on heavy, highly addicted smokers (Surgeon General Report,
2000). In develop countries the focus may need to be on individual treatment
interventions, including specialist smoking clinics and strategies to improve self-
quit attempts (Rutter, 2002).
Although previous empirical studies have shows that tobacco control
policies are effective at reducing smoking rates, such studies have proven of
limited effectiveness in distinguishing how the effect of policies depend on the
other policies in place, the length of adjustment period, the way the policy is
implemented and the demographic groups considered (Levy, 2005).
Barrier to ecological public health model is this model requires health
promotion to move out from the traditional health domain into a wider arena of
social and environmental practitioners is to overcome institutional constraints and
to break down the traditional disciplinary and territory barriers which obstruct
practice of the intersectoral activities required to integrate environmental and
health sectors.

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 Labonte (1992) provides a different perspective on approach to health. He
identified three model of health: medical or high-risk approach, behavioural or
multiple risk factor reduction approach, a socio-environmental or community
development (Labonte, 1992). He explains that the medical approach is reductive
and precise in focus; the behavioural approach accommodates the medical
approach and broadens it to incorporate behaviours and other factors that
influence those particular behaviours; and the socio-environmental approach,
which accommodates both previously mentioned models, is more inductive than
deductive and is broad ranging and multidimensional when seeking explanatory
relationship and planning ways to address health problem (Johnson, 2007).
Within the environmental determinants of health literature, attention is being
given to what constitutes health in terms of place or physical settings (Baum,
2008). The Ottawa charter for Health Promotion (WHO, 1986) identified the
impact of setting of everyday lives as the place where we ‘live, work, play, and
love’. The WHO delineates between contextual setting and elemental settings.
Contextual settings comprise the broader setting, such as cities, suburbs,
villages and island that play a major role in determinants a community level of
access to services and other social determinants of health. Element settings
include schools, homes, workplaces, hospital, marketplaces and other similar
settings that impact on the health of local communities (Jonhson, 2007).
Kerr (2000) identified that treating diseased or high risk individual does not
have much of an impact on the health of the populations a whole. But changing a
risk factors across a whole population by just small can have a large impact on
the incidence of a disease or problem in the community e.g. tobacco use.
Tobacco use affects for almost degenerative disease, reducing incidence rate
tobacco use affect significantly for lung cancer, coronary heart disease and
pulmonary disease.
Smoking bans in public places, whether mandated or voluntary, are
effective methods for reducing people’s exposure to second hand smoke. In
addition to protecting non smokers from involuntary exposure to tobacco smoke
toxins, such policies reduce cigarette smoking and may increase quitting rates

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among adult smokers. For example, workplace smoking bans reduce smoking
prevalence by approximately 10% and reduce cigarette smoking by 29%.
Restrictions on smoking in public places also produce environments in which
smoking is marginalized (Klarck, 2006).
Further more In the USA, Fichtenberg (2002) identified totally smoke-free
workplaces are associated with reductions in prevalence of smoking of 3.8% and
3.1 fewer cigarettes smoked per day per continuing smoker. Combination of the
effects of reduced prevalence and lower consumption per continuing smoker
yields a mean reduction of 1.3 cigarettes per day per employee, which
corresponds to a relative reduction of 29%.
There are several laws and regulations which are directly or indirectly
related to tobacco control in Indonesia, such as National Law No. 23 on Health,
Governmental decree No 81 about smoking and health as well as some local
regulation such as in Jakarta Bogor cities. But, these regulations have two
important limitations. First, they are not strong enough and do not cover all
aspect of a comprehensive tobacco control program, and secondly those
regulations have not been fully implemented or enforced. Tobacco control in
Indonesia will not move forward until the government evaluates and strengthens
existing laws, considers passing new strong laws and develops protocols for
enforcing all laws.

Conclusion
Prevalence rate tobacco use in Indonesia increases rapidly, among youth
ages 10 to 14 years old, the majority of those who ever use of tobacco were boys
(about 92 percent). For both boys and girls, the highest proportion of ever use of
tobacco was among those with age of 13 years old (about 41 percent) and
followed by those with the age of 14 years old (about 23 percent).
Tobacco use is a behavioural analysis related with behaviour change. In the
HBM, the model proposes that a person’s behaviour can be predicted based on
how vulnerable the individual considers themselves to be “Vulnerable” is
expresses in the HBM through risk and the seriousness of consequences.

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 Integrative program to control tobacco is motivational interventions. One
method of motivating smokers to quit is through tobacco control. This include
legislation to ban tobacco advertising and sale to young people, health
education, taxation to increase cigarettes prices, restriction of smoking in public
space, and product modification through the regulation of nicotine and tar
content. It has identified that treating diseased or high risk individuals does not
have much of an impact on the health of the populations a whole. Changing risk
factors across a whole population by just small can have a large impact on the
incidence of a disease or problem in the community.

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