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A skills training approach to smoking prevention among hispanic youth

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A skills training approach to smoking prevention among hispanic youth
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  Journal of Behavioral Medicine, Vol. 12 No. 3 1989 A Skills Training Approach to Smoking Prevention Among Hispanic Youth Gilbert J. Botvin,' Linda Dusenbury,' Eli Baker,l Susan James-Ortiz,' and Jon KernerZ Accepted for publication: October 21, 1988 The present study was designed to test the feasibility, acceptability, and ef- fectiveness of a 15-session smoking prevention intervention with a predominantly hispanic 74 ) sample of seventh-grade students (N = 471 in eizht urban schools in the New York area. The smokin~ evention cur- ricuhm teaches social resistance skills within the context of h broader inter- vention promoting general personal and social competence and was implemented in this study by regular classroom teachers. Results of logistic regression anal- yses provided preliminary evidence of the efficacy of this type of smoking prevention strategy with urban minority youth when implemented with a reasonable degree of fidelity. The significance of these findings is that they provide support for the generalizability of an approach previously found to be effective with white middle-class populations to a predominantly hispanic inner-city population. KEY WORDS: hispanic; adolescent; smoking prevention; resistance skills training; social in- fluence. INTRODUCTION Cigarette smoking has been the object of prevention and education ef- forts by teachers and health professionals for well over two decades. As the This research was supported by Grant 1 R18 CA 39280 from the National Cancer Institute. lCornell University Medical College, New York, New York 10021. >Memorial Sloan Kettering Cancer Center, New York, New York 10021. 279 0160-7715/89/0600-0279$06.00/0 O 1989 Plcnurn Pubhshlng Corporation  28 Botvin, Dusenbury, Baker, James-Ortiz, and Kerner evidence supporting the relationship between cigarette smoking and major chronic diseases such as cancer [U.S. Public Health Service (USPHS), 19821, cardiovascular disease (USPHS, 1983), and chronic obstructive lung disease (USPHS, 1984) has grown, these efforts have intensified. However, in spite of these efforts, cigarette smoking among adolescents has continued at un- acceptably high levels. Conventional approaches to smoking prevention have relied almost ex- clusively on the dissemination of factual information concerning the adverse health consequences of smoking. An implicit assumption of these approaches is that if individuals were sufficiently aware of the adverse health consequences of smoking, they would make a rational decision not to smoke. In addition to the provision of factual information, fear arousal tactics have frequently been utilized in an effort to increase the power of antismoking messages. Although these approaches have proliferated, the existing evidence over- whelmingly indicates that they are not effective (Botvin, 1986; Evans et al., 1979). Recent developments in the field of smoking prevention have provided empirical support for the efficacy of approaches which target the major psy- chosocial factors implicated in the onset of adolescent cigarette smoking (Bot- vin and McAlister, 1982; Evans et al., 1979; Flay, 1985). In their earliest form, these approaches were based on the notion of psychological inocula- tion (Evans, 1976). As they evolved, the primary conceptual orientation shifted from communications theory (McGuire, 1968) to social learning theory (Bandura, 1977). The strategies utilized have also shifted from those designed to inoculate adolescents by gradually exposing them to the various social influences to smoke to strategies which have been designed to provide them with the requisite skills for actively resisting those influences (Botvin and McAlister, 1982). The latter approach has relied largely on the use of peer leaders and behavioral rehearsal in the classroom. Notwithstanding the generally impressive results of the newer psychoso- cia1 approaches to smoking prevention, a major limitation is that virtually all of the existing research has been conducted with predominantly white, middle-class populations. Little is currently known concerning the extent to which these approaches are effective with urban, minority adolescents. Several factors could potentially attenuate the effectiveness of even the most promising psychosocial approaches to smoking prevention when im- plemented with urban, minority youth. First, since there is a paucity of basic research data concerning the smoking initiation process with minority popu- lations, the factors promoting and maintaining cigarette smoking may be sufficiently different for these populations to require a different prevention strategy. Second, the many problems associated with inner-city schools may make it difficult to implement this type of prevention program with the degree of fidelity and completeness necessary to be effective, thereby undermining  Smoking Prevention 28 1 feasibility. Finally, unless the material presented is culturally sensitive, it may not be acceptable to the target population. The present study is part of a larger investigation designed to extend the findings of previous smoking prevention research with psychosocial ap- proaches from predominantly white, middle-class, suburban populations to urban minority populations. The approach being tested teaches social resistance skills within the context of a broader intervention promoting general personal and social competence (Botvin et al. 1980, 1983). The study reported in this paper was designed to pilot test the feasibility, acceptability, and poten- tial efficacy of this type of prevention strategy with predominantly hispanic students attending urban public schools prior to conducting a large-scale, 3-year field trial. METHOD Subjects A total of 471 seventh-grade students (46% male) participated in this study. The mean age of students at the time of the pretest was 12 years, 11 months. These students attended eight public schools in the metropolitan New York/New Jersey area which served lower-income, urban minority stu- dents. Three schools were located in northern New Jersey; five schools were located in New York City. The sample consisted of predominantly hispanic students (74%), as well as a small percentage of black (1 1 Vo and white (4%) students. The remain- ing 11 classified themselves as Oriental, Asian, native American, or other racial heritage. The majority (54%) of the hispanic students identified them- selves as Puerto Rican, 10% as Dominican, 3% as Cuban, 3 as Ecuadori- an, 1% each as Colombian and Mexican, and 2% as being a member of an other hispanic subgroup. Procedure The universe of schools eligible for the study consisted of public schools in the greater New York area whose student body was at least 50% hispanic. Of 12 school districts considered eligible, 6 school districts with a total of 16 eligible schools were targeted for inclusion in this study based on size and location. Although no schools refused to participate, the process of obtain- ing administrative clearance was slower in some schools than in others. Recruitment continued until the recruitment goal of eight schools was reached.  282 Botvin Dusenbury Baker James-Ortiz and Kerner An equal number of schools was randomly assigned to experimental and control conditions. All seventh-grade students in mainstream English- speaking classes from participating schools were included in the study. All subjects completed a pretest questionnaire which was administered in class by teams of three to five trained data collectors. While completing the ques- tionnaire, students were also asked to provide a breath sample using a vari- ant of the bogus pipeline procedure in order to increase the validity of self reports of smoking behavior (Bauman and Dent, 1982; Murray et al., 1987). Students in the experimental condition participated in the 15-session smoking prevention program which was implemented by regular classroom teachers. Students in the control condition received only the smoking educa- tion curriculum usually provided by those schools. Approximately 3.5 months after the pretest, all students were posttested using the same questionnaire and data collection procedures as the pretest. Smoking Prevention Curriculum The intervention strategy used in this study included social resistance skills training and material designed to facilitate the development of impor- tant personal and social skills. The goal of the program is to provide adoles- cents with the requisite knowledge and skills for resisting social influences to smoke as well as to reduce potential motivations to smoke by increasing personal competence (Botvin, 1982). The prevention curriculum addresses major cognitive, attitudinal, psychological, and social factors which are either empirically or conceptually related to adolescent cigarette smoking. Descrip- tions of the intervention are contained in previous reports of evaluation research with this approach (e.g., Botvin et al., 1983). Since previous research with this approach has involved predominant- ly white suburban students, it was subjected to an extensive review prior to implementation in order to increase its appropriateness for an urban minority population. The review process involved four levels of review: (1) an inter- nal review by two psychologists and two hispanic health educators, (2) an external review by two experts on hispanic cultural issues, (3) a review by two reading specialists to determine the appropriateness of the reading level of student materials, and (4) a review of student materials by 59 urban rninori- ty adolescents similar to those who participated in the evaluation study. For levels 1 through 3, the curriculum review involved an iterative process which occurred over three or more meetings in which potential areas of modification were discussed. The feedback solicited from adolescents (level four) involved having them complete a brief anonymous survey after review- ing the student materials. According to the responses on this survey, 94% of these adolescents found the student materials to have a reading level that  Smoking Prevention 83 was either just right or easy (with 6% reporting that the reading level was hard ), 90% found the material to be either interesting or very in- teresting (with 10% reporting that they thought it was boring ), and 100% found the student material to be either important or very important. None of the adolescents indicated that they found any of the material to be cultur- ally insensitive. No revisions were suggested or made concerning the underlying preven- tion approach used in our previous research with white, middle-class adoles- cents. Rather, the recommendations resulting from the curriculum review process involved issues relating to reading level (e.g., vocabulary and sen- tence structure), the nature of the examples used to illustrate program con- tent, and the nature of the situations used for role-play exercises. Based on the recommendations resulting from this review process, revisions were made in the prevention curriculum. The prevention program was implemented by regular classroom teachers who had attended a I-day teacher training workshop. The purpose of the workshop was to familiarize teachers with the content of the prevention pro- gram and to provide them with an explanation for the rationale of the pro- gram. The workshop included a brief overview of the problem of cigarette smoking and its etiology, as well as a review of the results of evaluation studies testing traditional informational approaches to smoking prevention and past research with this prevention approach. The majority of the workshop was devoted to discussion, demonstration, and rehearsal of the prevention cur- riculum activities. Measures of Program Implementation In order to assess the completeness and quality of program implemen- tation, trained observers monitored randomly selected classes taught by each of the five intervention teachers. Two types of data were collected during these observation sessions. First, using observation forms developed for each prevention session, the observer recorded the curriculum points and objec- tives (corresponding to those detailed in the teacher's manual) covered dur- ing the particular session observed. From this, a quantitative assessment of the completeness of program implementation was calculated based on the proportion of points and objectives actually covered in class. Second, using Likert-type scales on a standardized observation form designed to be used with any intervention session, observers assessed the ef- fectiveness with which the teacher implemented the program, the degree to which the teacher appeared prepared to implement the program, the atti- tude of the teacher toward the prevention program and toward students, and the extent to which the students actively participated in the program. Scores
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