Volume 19, Issue 1 (2023)                   ioh 2023, 19(1): 349-361 | Back to browse issues page

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Torbat heydariyeh university of medical sciences , alizadeh1@thums.ac.ir
Abstract:   (779 Views)
Guild merchants have always been known as a section of society that in the context of economic and social developments have had a wide and effective position and function in various fields. In the Iranian economy, guilds, as the last economic link, have a special importance in the growth and dynamism of the country's economy and act as the economic heart of society due to their breadth and direct relationship with individuals (1). One of the high-risk behaviors among this group is the consumption of different types of smokeless tobacco (SLT) products (2). The term smokeless tobacco refers to the consumption of unburned tobacco in the form of chewing, spitting, dipping and snuff (2). There are usually a variety of SLT products (at least 40 types) in the world, including: Pan, Pan-Prague, Gutkha, Naswar (Nass), Mava and BT, Chaini Khaini, Zarda Pako , Supari and Manipuri (2).Smokeless tobacco (SLT) consumption annually causes the death of more than 250,000 people worldwide, with the majority of these deaths (85%) occurring in Southeast Asia (1). SLT products are highly addictive due to their high concentration of nicotine and contain more than 3,000 chemicals (2). At least 28 carcinogenic chemicals have been identified in SLT products, of which tobacco-specific nitrosamines and N-nitrosonornicotine are the primary carcinogens (3). SLT products increase the risk of tooth decay, esophageal cancer and pancreas. In addition, consumption of SLT products causes respiratory cancer, infertility, gastrointestinal cancer, acute hypertension, increased risk of cardiovascular disease, diabetes, preterm birth, Low Birth Weight (LBW), anemia Iron deficiency and nicotine dependence (4-7).
In order to understand and determine the factors affecting the consumption behavior of tobacco products, various models and theories of behavioral sciences have been used. Different models of behavior change and psychology are very helpful in understanding the factors affecting behavior or non-compliance with health care instructions (11). One of these theories is the Trans Theoretical Model. This model is a complete and coherent model that predicts how behavior changes and when (12). This model helps to understand when people are ready for change (the stages of preparation for change) and how to weigh the advantages and disadvantages of smoking (decision balance) based on their beliefs about individual abilities. Environmental capacities and existing real and mental barriers overcome the tempting situations of smoking (perceived self-efficacy). The model consists of 4 structures: stages of change preparation, balance in decision making, self-efficacy and change processes. The structure of the stages of change includes 5 stages, which are: pre-contemplation, contemplation, preparation, action and maintenance. The above five stages for tobacco consumption behavior are defined as follows: The pre-contemplation stage of the person consuming tobacco products does not think about quitting at all. In the contemplation phase, the person smokes, but considers quitting within the next 6 months. In the preparation phase, the person continues to use tobacco, but plans to quit smoking within the next month. The stage of action in which people have practically quit smoking but have been doing so for less than 6 months and the maintenance phase at which the person has quit smoking for more than 6 months (12). Despite the great potentials of this model and proving its effectiveness, in various searches, a study that used this model in designing educational interventions aimed at temptation / self-efficacy of SLT products was not found. Therefore, due to the lack of a study on the subject of research in Iran, this study was conducted to determine the effect of education based on transtheoretical model on the temptation / self-efficacy of SLT products among guild traders.
The present quasi‑experimental study was conducted among Chabahar merchants’ guilds using one intervention group. Inclusion criteria include: being 20 to 50 years old, consuming at least one form of SLT products (pan, pan parague, gutkha, mava, naswar, BT or khaini, pan masala), having the consent to participate in the study and having the business license and those who were seasonal guilds were excluded from the study.
According to the results of a similar study (14) the participants’ mean score of SLT consumption was 3.59 before the intervention, which reached to 3.86 after the intervention. Considering a 95% confidence interval and 80% probability of sample size, a total of 310 individuals were selected. Ultimately, to increase the study accuracy and reduce the effects of sample loss, this study was conducted on 320 individuals.
The data collection tool was a researcher-made questionnaire that consisted of two parts: the first part included demographic characteristics (age, gender and type of business) and the second part was related to the temptation/ self-efficacy questionnaire. The questionnaire consisted of 9 questions, each of which contained the infrastructure of positive social situations, negative situations and habitual situations. Each of the 3 scales was designed with a 5-point Likert scale. In this study, participants were asked to rate their temptation to consume their SLT products based on a 5-point Likert scale in any of the proposed conditions; not much; relatively; very; too much. In this study, CVR and CVI were calculated to be 0.85 and 0.9, respectively, and Cronbach's alpha and ICC were estimated to be 0.76 and 0.84, respectively.
The educational methods used in the mentioned classes were based on short lectures, questions and answers, group discussions with videos and photos related to the destructive effects of tobacco products on general health and oral health, and using data projectors and PowerPoint. The topics discussed in the two sessions were: Session 1) Types of smokeless tobacco products and their ingredients, the effect of tobacco on the circulatory system, cardiovascular system, respiratory system, gastrointestinal tract, mouth, gums and teeth, diseases caused by consumption of tobacco products, especially cancers, Session 2) Negative attitudes about consuming smokeless tobacco products (role of tobacco products in calming the nerves, relieving fatigue, etc.), temptation and addiction to tobacco products, negative social effects of consuming these products, negative views of society and real friends, Obstacles in the path of quitting tobacco and proposed solutions, scientific and correct methods of quitting tobacco products and the benefits of quitting these products. After 6 months from the intervention, the information of the questionnaire was collected again after prior coordination and by visiting the facilitators in person at the workplace of the subjects.
Descriptive and inferential statistical methods were used to describe and analyze the data. Data were presented as mean (standard deviation) for quantitative data and frequency (percentage) for qualitative data. Tests (ANOVA, Tukey and paired t-test) were used in data analysis. Values of P <0.05 were considered significant and SPSS 20 software was used for analysis.
According to the results of the study, most of the merchants were Textile and clothing class (19.4%) and most of them were between 20-30 years old (Table 1).
Table 1: Determining the demographic variables of guilds
Variables Groups Ferquency Percentage
Age 20-30 years 221 69.1
30-40 years 77 24.1
40-50 years 22 6.8
Gender Male 198 62.0
Female 122 38.0
Guilds Bakers and confectioners 13 1.4
Textile and clothing 62 19.4
Grocers and perfumers 46 14.4
Car and motorcycle repairmen 37 11.6
Hairdressers and cosmetics 61 19.1
Tailors and embroiderers 25 7.8
Hoteliers and restaurants 7 2.2
Door and window makers and lathes 9 2.8
wholesalers of food 33 10.3
Others 27 8.3
The mean scores of the whole structure of temptation / self-efficacy before and after the intervention were 16.53±1.64 and 9.22±2.71, respectively. The results of paired t-test show that the mean score of this structure after the intervention was significantly lower than the mean score before the intervention and this difference was statistically significant (P-Value <0.001). The mean score of positive, negative and habitual situations of temptation / self-efficacy components after the intervention was lower than before the intervention, which was statistically significant (P-Value <0.001) (Table 2).
Table 2: Determining and comparing the mean score of temptation / self-efficacy and its components before and after the intervention
Temptation/self-efficacy Before the intervention After the intervention Minimum Maximum Mean difference P-Value
(Paired T Test)
  Mean SD Mean SD
Positive situations 7.91 1.04 4.28 1.5 2 10 -3.63 <0.001
Negative situations 4.72 0.45 2.46 1.08 1 5 -2.26 <0.001
Habitual situations 3.9 0.7 2.5 1.3 1 5 -1.4 <0.001
Total 16.53 1.64 9.22 2.71 4 20 -7.31 <0.001
Before the intervention, the mean scores of temptation/self-efficacy of smokeless tobacco products in positive situations among pre-contemplation and contemplation individuals were 7.98±1.01 and 7.82±1.00, respectively. Also, the mean scores of guild traders in negative situations in individuals in the pre-contemplation and contemplation stage were 4.73±0.44 and 4.75±0.43, respectively and according to the ANOVA statistical test, there was a significant relationship between the stages of change and the structure of temptation/ Self-efficacy was present in positive, negative and habitual situations (P-Value <0.05) (Table 3).
Table 3: Determining and comparing the mean score of temptation/ self-efficacy according to the stages of change before the intervention
Temptation-self-efficacy Stages of change P-Value (ANOVA)
Pre-contemplation contemplation Preparation
Positive situations 7.98±1.01 7.82±1.00 6.00±0.00 <0.001
Negative situations 4.73±0.44 4.75±0.43 4.14±0.69 0.003
Habitual situations 3.93±0.7 3.88±0.68 3.14±0.37 0.014
Temptation/self-efficacy 16.63±1.59 16.45±1.51 13.28±0.48 <0.001
According to the results of Table 5, the mean score of temptation/ self-efficacy in terms of stages of change in the post-intervention stage in habitual situations in individuals in the pre-contemplation and contemplation stage was 2.67±1.26 and 2.83.±1.32, respectively. The mean score of temptation/ self-efficacy of smokeless tobacco products in guild trades in negative situations in people in the pre-contemplation and contemplation stage in the post-intervention was 2.54±1.15 and 2.5±1.05, respectively.
Table 5: Determining and comparing the mean score of temptation/ self-efficacy according to the stages of change after the intervention
Temptation-self-efficacy Stages of change P-Value (ANOVA)
Pre-contemplation contemplation Preparation Action Maintenance
Positive situations 4.76±1.17 4.61±1.37 4.94±1.38 3.4±1.6 3.12±1.33 <0.001
Negative situations 2.54±1.15 2.5±1.05 2.63±1.06 2.34±0.99 2.2±1.11 0.238
Habitual situations 2.67±1.26 2.83±1.32 3.04±1.22 1.95±1.25 1.76±0.94 <0.001
Temptation/self-efficacy 9.97±2.09 9.94±2.26 10.61±2.18 7.70±2.83 7.08±2.58 <0.001
The aim of this study was to determine the effect of education based on Trans-theoretical model on the temptation/ self-efficacy of SLT products among guild traders. In general, the results showed that the intervention was effective in reducing the consumption of SLT products. The results of the present study in the pre-intervention stage showed that the mean scores of negative situations and the temptation to consume SLT products had the highest value, followed by positive situations and the lowest were related to negative situations. This finding suggests that negative situations such as anxiety, anger, and frustration cause the person to slip and be tempted to use SLT products, reducing people's self-efficacy in overcoming and adapting to these situations. On the other hand, positive situations such as parties, celebrations and being in the company of friends can also increase the temptation to consume SLT products, because in these situations the pressure of others, friends and peers can also tempt the consumption of these products. The findings of the present study are the same as those of Farkich et al. (15) and Minilk et al. (16). The results of the study by Wagner et al. (17) showed that the negative situations of smoking temptation, both in healthy people and in patients with chronic disease, had the highest value, which was followed by positive and habitual situations. They assigned the amount to themselves, which did not agree with the findings of the present study.
Also, the results of the present study in the pre-intervention stage showed that the mean scores of temptation in all situations (positive situations, negative situations and habitual situations) among people in the preparation stage were significantly lower than the people in the pre-contemplation stage. Was. This finding is similar to the expected Trans-theoretical model. According to this model, it is expected that with the movement of people from the pre-contemplation stage to the preparation stage, the average scores of the temptation to use tobacco will decrease. The results of Kim's (20) study on Korean adolescents showed that the temptation to smoke was greater in pre-contemplation individuals than in preparation individuals.
After the intervention, the mean scores of the subjects' temptation to consume SLT products in all situations (positive situations, negative situations and habitual situations) decreased and their self-efficacy to overcome tempting situations increased. In the study of Hekmat Po et al. (23), Adelman et al. (24) and Hong et al. (25), following the educational intervention, the temptation of the treatment group decreased and their self-efficacy increased significantly. The findings of the study conducted by Mehrabizadeh Honarmand et al. (26) are consistent with the findings of our study in this section. In the study of Kim et al. (27), although the mean scores of temptation in positive, negative and habitual situations had decreased, but the difference in mean scores before and after the intervention was not significant, which is not fully consistent with the results of the present study. One of the possible reasons is the difference in demographic characteristics of the subjects in the study with the findings of the present study.
By designing and implementing interventions based on the transtheoretical model, it is possible to reduce the temptation of people consuming these products in different stages of change and increase their self-efficacy to overcome tempting situations. Due to insufficient cost allocation and large volume of research samples, it was not possible to provide Nicotine Replacement Therapy (NRT). Considering the effectiveness of the intervention on reducing the consumption of smokeless tobacco products in the present study, it is suggested that this intervention model be used in other cities, especially the cities of Sistan and Baluchestan province.
The authors declare that there are no conflicts of interest regarding the publication of this manuscript.
Article number: 23
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Type of Study: Research | Subject: Aplication of Behavior's change models
Received: 2021/12/29 | Accepted: 2022/09/8 | Published: 2023/03/12

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