Abstract
Purpose:
Tobacco use is a major public health issue in developing countries, with substantial initial exposure in childhood. School-based educational resources promise to reduce tobacco initiation and experimentation among children from low-income countries. Research in this area is scant. The study goal was to test the impact of an evidence-based US educational resource on tobacco-use health risk knowledge among Tanzanian children.
Methods:
Eglin Long-Horn of Nightshade County is a potentially transferable children’s storybook/curriculum focused on reducing tobacco-use intent. A pre-/post-survey assessed the impact of ‘Eglin’ on knowledge of tobacco exposure health risks among secondary school-age residents of a Tanzanian children’s home.
Results:
Of the 52 participants, 35 returned both surveys. School grade ranged from Forms 1 to 4, with 51% in Forms 1–2 (ages 14–15). There was an overall increase from 60% to 93% (p < .0001) in correct survey responses, with an increase seen in all grade levels.
Conclusion:
A US-based tobacco awareness storybook/curriculum improved Tanzanian children’s knowledge of tobacco-use health risks.
Introduction
Increasing tobacco use is a major public health crisis in developing countries like Tanzania (Agaku et al., 2013; Bauer and Kreuter, 2015; Guindon and Boisclair, 2003). Efforts to reduce global tobacco addiction rates should be directed at children because most tobacco initiation occurs before the age of 18 years (Bauer and Kreuter, 2015). Nicotine addiction follows five established stages: (1) susceptibility to smoking (never smoked), (2) initiation (trying the first cigarette), (3) experimentation (repeatedly trying cigarettes – early signs of addiction), (4) establishment of smoking (regular smoking – likely signs of addiction), and (5) nicotine dependence (Bauer and Kreuter, 2015). Children are particularly vulnerable to stages (2) initiation and (3) experimentation. Transition from experimentation to addiction typically takes up to 2 years, although children may be susceptible to more rapid dependence (Bauer and Kreuter, 2015; DiFranza et al., 2011). Young people often underestimate the hazards of tobacco use and the risk of addiction to these products (Amrock and Weitzman, 2015; Slovic, 2000). Furthermore, the likelihood of addiction is greater the earlier the exposure to tobacco (Bauer and Kreuter, 2015; Breslau and Peterson, 1996; DiFranza et al., 2011). According to World Health Organization (WHO, 2015b) data, 250 million young people who continue smoking into adulthood will die from tobacco-related diseases, including cancer; focused concern is on under-resourced countries where 80% of the world’s children live.
These data highlight the need for tobacco-related educational efforts among children from low-income countries aimed at early awareness of the health hazards of tobacco use and prevention of tobacco-use initiation, as well as advocacy efforts directed at limiting childhood tobacco exposure. US-based evidence shows that community/school-based educational efforts reduce the risk of smoking initiation among children and adolescents (US Preventive Services Task Force, 2013). A global study of never-smoking youth, including African adolescents, showed that school-based anti-tobacco education is associated with reduced susceptibility to smoking (Veeranki et al., 2014).
Data from Dar es Salaam, the largest city in Tanzania, has shown that 13.3% (95% confidence interval [CI]: 11.8%–14.9%) of primary and secondary students report that they have ever tried/experimented with cigarettes. Of these, the proportion of students reporting cigarette experimentation increased from 11.8% among those aged 7 or younger to 26.4% among those aged 12–13; 64.5% of those who reported experimenting with cigarettes were boys (Kapito-Tembo et al., 2011). Lack of awareness of the hazards of cigarette and non-cigarette tobacco products is presumed to contribute to tobacco initiation among Tanzanian children. To date, there have been few tobacco educational resources available to parents, public health officials and teachers in Tanzania. In contrast, educational and awareness resources are more plentiful in developed countries, including the US. Studies of the impact of community/school-based educational resources to improve knowledge of the hazards of tobacco use among Tanzanian children have been scant, and the adaptability/transferability of existing US resources to the Tanzanian context is uncertain.
We hypothesised that select, validated US-based educational materials may be of value in the Tanzanian context, providing the potential to improve the school-aged child’s knowledge of the health hazards of tobacco. As storytelling has been used to promote health literacy in a universally relevant, understandable and appealing way (Day, 2009), we tested this hypothesis through examination of the knowledge impact of an existing evidence-based US educational storybook/curriculum, Eglin Long-Horn of Nightshade County (Wert, 1998), among a cohort of Tanzanian secondary school children.
Through seed funding from the American Society of Clinical Oncology, this work capitalised on existing US–Tanzanian professional and community-based partnerships and facilitated involvement of education experts. It included a range of stakeholder groups – public health, medicine, education and non-governmental organisations – who have interest in the long-term health of Tanzanian children.
Methods
Educational resource
Eglin Long-Horn of Nightshade County (Wert, 1998), written by a health education specialist, is a potentially transferable 1 and translatable children’s storybook that is focused on increasing elementary school-aged children’s awareness of the health hazards of tobacco use, with the goal of reducing tobacco-use intent. The Eglin Long-Horn of Nightshade County Teacher’s Guide, used in conjunction with the storybook, was developed as a tool to guide parents, other relatives and teachers in educating children about the importance of tobacco-use prevention.
Through the experiences of a grasshopper, Eglin, the book allows the child and educator to explore the chemical makeup of tobacco; the physiological, cosmetic and social consequences of tobacco use; as well as the long-term health risks of tobacco use, including the risks of second-hand smoke exposure. Previous study of the impact of this book among a representative sample of over 1,700 primary school children from 97 Florida (US) schools revealed a significant increase in knowledge of the health hazards of tobacco use among the children exposed to the storybook/curriculum compared with a control group not exposed (James et al., 2003).
After review of available evidence-based US educational resources aimed at reducing tobacco-use initiation among young children, the study team selected Eglin Long-Horn of Nightshade County for this work because it was (1) a storybook potentially culturally and socially transferable to the Tanzanian context, (2) testable within the local setting, and (3) relevant for both school and residential use. The storybook was used without adaptation for this study, and the work reported here reflects the initial test of this intervention relative to gain in knowledge of the health hazards of tobacco use among Tanzanian children.
Survey instrument
A validated survey instrument, developed for earlier study of the educational impact of Eglin Long-Horn of Nightshade County among young children, was used for this work. The survey contains 34 questions, including 16 questions reflecting knowledge of tobacco-use health hazards, as well as 18 questions reflecting knowledge of insects and understanding of vocabulary used in the storybook. As our study was focused on examining the impact of this educational resource on children’s knowledge of the health consequences of tobacco use, our pre-/post-survey instruments included only the 16 tobacco risk knowledge questions. Cronbach’s alpha was .64 in an earlier US-based study assessing internal consistency of this 16-item knowledge test (James et al., 2003). Among these questions: 11 were multiple choice, one was yes/no, and the remaining four were fill in the blank. Responses to questions were scored as correct or incorrect. An individual’s knowledge score was determined based on the percentage of correct answers out of a total of 16.
Study setting and subjects
Both the public sector and the private sector are involved in the Tanzanian education system. The general structure includes 2 years of pre-primary education for ages 5–6, followed by 7 years of primary education for ages 7–13 (Standards I–VII), 4 years of secondary ordinary level education for ages 14–17 (Forms 1–4), 2 years of secondary advanced level education for ages 18–19 (Forms 5 and 6), concluding in 3 or more years of university education. There are no tuition costs for students attending government primary schools; however, families pay for school supplies. Tuition fees are levied beginning in Form 1 (secondary school).
Kiswahili is Tanzania’s official language, used as the means of instruction in primary schools. English is taught as a subject from Year 3 of primary school onwards, and is the language of instruction in secondary schools and post-secondary institutions of higher learning. All primary school textbooks, except English textbooks, are written in Kiswahili. English textbooks are used in secondary schools and institutions of higher learning. Because of concerns about potential language barriers among younger (primary school) children, this work involved secondary school children (Forms 1–4).
The storybook was tested as a means to increase knowledge of the health hazards of tobacco use among a self-selected cohort of residents of a permanent children’s home for orphans, founded by an American in partnership with a Tanzanian. Two members of the study team had established working relationships with the organisation’s administrators, and approval for this work was secured from its Director. The study was determined exempt from institutional review board approval because it related to education/curriculum development. All data were collected without participant identifiers.
Test of educational resource
With the support of the Teacher’s Guide, a US children’s home volunteer who, at the time of study, was a college graduate with an education background, facilitated the Eglin Long-Horn of Nightshade County test. The volunteer met with study participants to assess the impact of the book over the course of one week during their 2014–2015 winter school recess. Following completion of the pre-survey, the volunteer directed students in reading the storybook. She regularly engaged them in discussion of the storybook’s contents and collected post-surveys upon completion of the book. All study materials were presented in English, including the storybook and pre-/post-survey instruments.
Statistical methods
We used numbers (n’s) and percentages to describe categorical variables (i.e. education level) and means to describe continuous variables (i.e. knowledge scores). Paired t-tests were used to assess the statistical significance of pre/post differences in knowledge scores.
Results
Participants
A total of 52 children participated in this study. All read and reviewed the book’s contents in the presence of the study-affiliated volunteer and responded to pre-/post-surveys. Of these, 35 returned both surveys; 17 returned only one pre- or post-survey. Table 1 shows that among the total cohort of 52 children, school grade ranged from Form 1 to Form 4 (ages 14–17 years). Among those participants returning both surveys, the majority (51%) were in Forms 1 and 2 (ages 14–15); six students (17%) did not report a grade; two noted they were “pre-Form 5”.
Educational level of study participants.
Survey results
Figure 1 shows that among those returning both surveys, there was a statistically significant increase from 60% to 93% (p < .0001) in the mean percentage of knowledge questions answered correctly. Increased knowledge was seen among all grades studied. Among the younger children (Forms 1–2), pre- and post-scores appeared lower than among older children (Forms 3–4). In contrast, the total increase in scores was greater among the younger group (i.e. increase in mean percentage of correct responses totalling 35% and 30%, respectively).
Change in knowledge by grade (form).
Discussion
Tobacco use is among the most preventable causes of morbidity and mortality worldwide. Globally, over 5 million deaths (the equivalent of one in 10 deaths) annually are attributed to tobacco use (WHO, 2015a). This number is expected to exceed 8 million in 2030 (WHO, 2008), with at least 80% of these deaths occurring among those from developing countries (WHO, 2008, 2013).
Most adult smokers become tobacco dependent in their teenage years. The need for effective educational/awareness resources focused on educating children on the health hazards of tobacco use as a means to reduce tobacco-use intent has been acknowledged globally (Bauer and Kreuter, 2015). Despite calls for tobacco prevention efforts in low-income countries, youth-focused educational capacity building, and research and advocacy in this area have been limited in countries like Tanzania (Agaku et al., 2014; Kaduri et al., 2005; Steptoe et al., 2002; US Preventive Services Task Force, 2013; WHO, 2006, 2010, 2015a).
Using lessons learned from an evidence-based US educational resource that was viewed as potentially transferable and culturally relevant to the Tanzanian context, Eglin Long-Horn of Nightshade County was selected for testing among secondary school-aged children from Northern Tanzania. Through pre-/post-evaluation of knowledge gained, this work revealed that this resource increased knowledge of the health hazards of tobacco use among the self-selected cohort studied. To our knowledge, this is the first test of the effectiveness of this type of US-based educational resource in Tanzania. Although this work builds on existing efforts to prevent initiation of tobacco use among US children, it is innovative in its extension of this work to the Tanzanian context. It is unique in its involvement of end-users and lay educators.
Although a concern at study outset, language and cultural barriers did not seem to be impediments to successful completion of this work. Specifically, although Kiswahili is the primary language in Tanzania, the study involved English versions of the storybook and survey instruments. This did not appear to affect either the review of the storybook or the completion of pre-/post-surveys. Furthermore, as the book’s principal character was an insect, there were no apparent major cultural or social barriers to using this educational resource within the context of the study.
Limitations
There are significant limitations to this study. First, it involved a small self-selected cohort of secondary school children residing in a permanent home for orphaned children. Furthermore, the study involved a US volunteer working within the organisation. This limits the generalisability of this work to the greater Tanzanian school and home settings. It also limits the transferability of study results to younger Tanzanian children, which is significant given the book was developed for elementary school-aged US children. Second, we recognise that the largely descriptive findings reported here are prone to several biases and confounding. Third, we only measured improvement in knowledge of the health risks of tobacco use. We did not assess changes in the students’ attitudes regarding intent to initiate tobacco use. This is a noteworthy limitation of this study because improved knowledge may not translate into behaviour change. Fourth, we did not assess the children’s overall satisfaction with the storybook, an important issue relative to utility, scalability and sustainability. Next steps in this work include an examination of the impact of this educational resource among a broader population of Tanzanian children within the school-based setting. Further research in this area promises to facilitate improved understanding of and access to tobacco awareness resources among Tanzanian school-aged children and advocacy/policy in this regard.
Conclusion
A US-based educational storybook/curriculum holds promise to increase knowledge of tobacco-use health risks among children from a low-resource setting. Language and cultural barriers did not seem to be major impediments to the completion of this study. Select existing educational resources to prevent childhood tobacco-use initiation in the high-resource setting may be transferable to the Tanzanian context. Further research and advocacy in this area is needed.
Footnotes
Acknowledgements
The authors thank the children and children’s home staff who participated in the pilot test of Eglin Long-Horn of Nightshade County, as well as Norma Albrecht for her assistance in preparing this manuscript. This work is dedicated to Bertha Maegga who dedicated her professional life to the advancement of health services research responsive to improving the wellbeing of Tanzanians.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported in part by the American Society of Clinical Oncology’s Conquer Cancer Foundation International Innovation Grant Program.