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Effectiveness of Health Belief Model in Motivating for Tobacco Cessation and

to Improving Knowledge, Attitude and Behavior of Tobacco Users

Article · January 2014

DOI: 10.13189/cor.2014.020401

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Cancer and Oncology Research 2(4): 43-50, 2014 http://www.hrpub.org DOI: 10.13189/cor.2014.020401

Effectiveness of Health Belief Model in Motivating for Tobacco Cessation and to Improving Knowledge, Attitude

and Behavior of Tobacco Users

Piddennavar Renuka1,*, Krishnappa Pushpanjali2

1Dept of Public Health Dentistry, ACPM Dental College and Hospital Dhule 424001, Maharastra, India 2Dept of Public Health Dentistry, MS Ramaiah Dental College and Hospital Bengaluru 560054, Karnataka, India

*Corresponding Author: drrenukapiddennavar@gmail.com

Copyright © 2014 Horizon Research Publishing All rights reserved.

Abstract There is an alarming increase in tobacco use in younger generation & it is responsible for 90% of oral cancers. A quasi-experimental study was conducted in dental health care settings to assess the effectiveness of health education in improving knowledge, attitude and behaviors of current tobacco users, towards tobacco use, among the patients visiting dental health settings. Study comprised of 20-35 years 88 current tobacco users. Health education was based on the Health Belief Model (HBM). Questionnaire was used to assess knowledge, attitude, and behavior of subjects. Leaflet and video were prepared for aid in health education Descriptive analysis, Paired t-test, Stratified analysis, Pearson Correlation analysis were employed. Improvement in decision to enl in to the tobacco cessation program was 33.7%. There was a statistical significant improvement in knowledge and attitude, of all subjects, in behavior domain significant improvement seen in subjects aged between 20-25 years, literate, smokers, and those utilizing dental health care services more than once in a year. Results of this study concluded that health education based on HBM was effective in motivating to enroll in to tobacco cessation program and improving knowledge and attitude of the tobacco users towards tobacco use and in improving behaviors of younger subjects, literates, smokers and subjects utilizing the dental health services more than once in year.

Keywords Current Tobacco Users, Health Belief Model, Health Education, Oral Cancer

1. Introduction Tobacco use is one of the most important risk factors for

oral diseases including oral cancer, oral mucosal lesions, periodontal disease, and cleft lip and palate (1). An Estimated 2,63,900 new cases and 1,28,000 deaths from oral

cavity cancer (including lip cancer) occurred in 2008 worldwide. In South-central Asia, cancer of the oral cavity ranks among the third most common types of cancer (2). In India, the age standardized incidence rate of oral cancer is reported at 12.6 per 1,00,000 population (3). In India oral cancer ranks 1st in male and 4th in females among all cancers (2). If age standardized rate per 1,00,000 remains the same by 2015 incidence rate would be 50,174 in males and 28,245 in females (3).

Smokeless tobacco products and betel quid with or without tobacco are the major risk factors for oral cavity cancer in Taiwan and India. WHO has taken active initiative at micro and macro levels to control the tobacco epidemic (2). Health education is one such measure to control tobacco epidemic both at national and international level (4). Health education is one of several possible intervention strategies. It focuses on life style change in recognition of the importance of behavioral, cultural, social, and economic factor as determinants of disease. For behavioral intervention to be most effective, health education should be theoretically driven, targeted at specific behaviors, aimed at identified, vulnerable and high-risk groups. Based on evidence of needs and barriers to change within these groups it aims at offering repeated exposure to key messages, training in behavior change skills and also predict environmental input and support at a community or school level (5).

Health education models that can be applied at individual level, and suitable at dental clinical setting are Health Belief Model (HBM), Stages of Change Model and Theory of Reasoned Action (6). HBM is a good model for addressing problem behaviors that evoke health concerns. HBM has been used to help in developing messages that are likely to persuade an individual to make a healthy decision. Studies have found strong associations between good oral health and HBM stages (6-8). But its application in improving knowledge, attitude and behavior of tobacco users’ has not been assessed as per the literature search conducted. With this background a quasi experimental study has been

44 “Effectiveness of Health Belief Model in Motivating for Tobacco Cessation and to Improving Knowledge, Attitude and Behavior of Tobacco Users”

conducted to assess the effectiveness of health education based on HBM in improving knowledge, attitude and behaviors of current tobacco users, towards tobacco use, among the patients visiting the outreach centers of M.S. Ramaiah Dental College and Hospital, Bengaluru, India.

2. Materials and Methods Source of the study subjects were the patients visiting the

outreach centers of M S Ramaiah Dental College and hospital. Subjects aged between 20 – 35 years who are current users of tobacco (smoking & smokeless form) were included in the study. Permission to conduct the study in peripheral outreach centers and ethical clearance of the study was obtained from authorities and institutional review board of M S Ramaiah Dental College and Hospital, Bengaluru. Written informed consent obtained from the subjects before enrolling in to the study. Current tobacco users were defined as “A person who had used tobacco (at least once per day) right up to the point at which he/she entered the dental setting” (9). Subjects who are unable to comprehend the health education provided i.e. visually impaired, auditory impaired, mentally challenged, language barrier etc were excluded from the study.

A tool was developed to assess the knowledge, attitude, and behaviors of tobacco users regarding tobacco use. Development of questionnaire done in following steps (10-19)

1. Identification of domains 2. Decided on information to be required in each domain

as per current literature on tobacco and its ill-effects 3. Determining the type of questions 4. Determining the sequence of items 5. Pretested the questionnaire Content validity, (18, 21) linguistic validity (17) and

reliability of developed questionnaire was assessed appropriately and necessary revisions were made. The tool also included socio-demographic details, health service utilization, and duration of tobacco use. Education and Occupation status of subject’ were recorded as per education and occupation component of Kuppaswami scale (20). Socioeconomic status was assessed using B G Prasad socioeconomic scale (21). Intervention planned in two stages:

1. Health education module development 2. Leaflet and Health education video development Development of health education module: Health

education was given in one to one bases. Following are constructs of Health Belief Model upon which health education was constructed:

1. The severity of a potential illness: a person's opinion of how serious this condition is E.g. Tobacco users should know the ill effects of tobacco use such as decreases apatite, decreased immunity, oral diseases that are due to tobacco consumption such as bad breath, periodontal diseases, oral cancers etc.

consequences of diseases on health and daily life. He/she also should perceive them as a threat and they can occur to him/her.

2. The person's susceptibility to that illness: a person's opinion of the chances of getting a certain condition; E.g. tobacco users should believe that he/she is susceptible to suffer from ill-effects of tobacco use.

3. The benefits of taking a preventive action: a person's opinion of the effectiveness of some advised action to reduce the risk or seriousness of the impact. E.g., Tobacco users should know how the oral health, general health and quality of life changes after quitting the tobacco.

4. The barriers to taking that action: a person's opinion of the concrete and psychological costs of this advised action. E.g., Tobacco users should weigh the benefits, which are going to change his quality of life with barriers, which are stopping him from quitting tobacco use.

5. Cues to action: They are stimulations, which facilitate decision-making. They act in two ways: some of them are internal like loss of appetite, reduced immunity, premalignant lesions, oral cancer in case of tobacco users. Some of the cues to actions are from outside like disturbed communication between people due to stained teeth, bad breath, due to oral cancer. In some cases it is reminding call from the physicians or by seeing at leaflets or other printed materials provided to the subjects.

6. Leaflet and health education video development: As a part of health education, leaflets were prepared based on well known guidelines (22-25). Leaflets served as a cue to action against quitting tobacco and motivating the subjects to enroll in to the tobacco cessation counseling. Leaflets were prepared based on the European Commission Guidelines for patient information leaflet and information packages (23). Types of tobacco products, ill-effects of tobacco use and benefits of quitting tobacco were depicted in pictorial form on A4 glossy paper design printed in full color. The expert panel assessed leaflets and necessary corrections made accordingly. Leaflets were assessed for face validity and cultural acceptance by interviewing the subjects about understanding meaning/information behind the pictures and health quotes. Video was prepared to aid in explaining facts about tobacco ill effects and benefits of quitting tobacco habit. Same pictures and quotes used in preparation of leaflets were used to prepare videos.

Out of 246 tobacco users visited to the peripheral outreach centers subjects with current tobacco use were 112. Among 112 subjects, 24 subjects eliminated for not filling inclusion criteria. Seventeen subjects did not give consent for the study, five subjects were non-Kannada speaking and two patients had oral cancer and were advised for the surgery. Finally, 88 subjects enrolled in the study.

Cancer and Oncology Research 2(4): 43-50, 2014 45

Table 1. Socio-demographic depiction of subjects

Variables N (%)

Gender Male 27 (30.7)

Female 61 (69.3)

Age

Mean age 29.58

20 – 25 years 18 (20.5)

26 – 30 years 29 (39. 8)

31 – 35 years 41 (46.59)

Education

Postgraduates 0 (0)

Bachelor Degree 4 (04.5)

Diploma 2 (2.3)

PUC 3 (3.4)

High school 13 (14.8)

Primary school 21 (21.6)

Primary school not completed

13 (13.6)

illiterate 42 (46.4)

Occupation

Professional 0

Semiprofessional 0

Skilled 2 (2.3)

Semiskilled 6 (6.8)

Unskilled 36 (40.9)

Unemployed 44 (50.0)

Socioeconomic status

Class I 0

Class II 1 (1.1)

Class III 13 (14.8)

Class IV 51 (58.0)

Class V 23 (26.1)

Duration of habit

Mean duration 6.74

1-5 years 41 (46.6)

6-10 years 25 (28.4)

> 10 years 22 (25.0)

Type of tobacco

Smoked 16 (18.2)

Smokeless 74 (81.8)

Dental health service

utilization

> 2 times in a year 3 (3.4)

2 times in a year 26 (29.5)

1 time in a year 40 (45.5)

First visit 19 (21.6)

General health Systemic illness present 3 (3.4)

Systemic illness absent 85 (96.6)

The investigator was trained and calibrated under the guidance of the professor. Before delivering Health education knowledge, attitude, and behavior of subjects’ towards tobacco use was assessed. Using a health education video health education was delivered individually for a period of 16 minutes. At the beginning-part, ill effects of tobacco use were explained there by making them realize about the severity of tobacco ill effects and their susceptibility to tobacco induced diseases and bad outcomes. Followed by various preventive modalities available for preventing tobacco induced oral cancer were put in plain words. Benefits of quitting tobacco habits, how to overcome and manage the barriers to quitting tobacco were informed. As a cue to action and reinforcement, leaflet was given and instructed to stick to the places where they usually see more. Subjects were informed to revisit after two months for follow-up.

In the follow-up, subjects were again re-interviewed by the same examiner for assessing the knowledge, attitude, and behavior. At this point subjects willing to quit the tobacco habits were referred to appropriate tobacco cessation cells.

The collected data were tabulated and subjected to statistical analysis using SPSS version 16. Descriptive analysis was employed for socio-demographic details of subjects and to describe the proportion of subjects in various quartiles. Stratified analysis was employed to assess the influence of the gender, age groups, occupation, type of tobacco use, duration of tobacco use and socioeconomic status on knowledge attitude and behavior scores. Pearson Correlation analysis was employed to assess the correlation between the different domains of the questionnaire.

3. Results Total 88 subjects were participated in the present study,

out of which males 27 (30.7%) and females 61 (69.3%). Mean age of participants was 29.5 years with standard deviation 4.59. Subjects were stratified by age into 20-25, 26-30 and 31-35 years. Most of the subjects were illiterate and not completed the primary school, unemployed, belonging to the semiskilled and unskilled workers. Most of the subjects were belonging to class IV and V socio-economic status. Mean duration of tobacco use was 6.74 (SD 4.145)and most of them used smokeless form of tobacco 74 (81.8%). 78.4% of subjects utilized the dental health care at least once in a year. Only 3 subjects were found to have systematic illness (Table 1).

Figure 1 depicts the shift of subjects mean scores from lower quartile in the baseline to higher quartile at follow-up in total scores, knowledge, attitude, and behavior domains. Table 2 depicts the mean scores in all the three domains, total scores, standard deviation and, minimum and maximum values at baseline and at follow-up of the subjects. Improvements in the knowledge, attitude domains and in the total score were statistically significant with p-value 0.000. Improvement in the behavior domain was not significant

46 “Effectiveness of Health Belief Model in Motivating for Tobacco Cessation and to Improving Knowledge, Attitude and Behavior of Tobacco Users”

with the p-value 0.218 (table 3). Stratified analysis of improvement in total score, knowledge, attitude and behavior domains showed that the variables with respect to gender, age, education, occupation, duration of tobacco use,

type of tobacco use and pattern of dental health service utilization were not found to be as confounders in improvement in mean scores of group in total scores, knowledge, and attitude domains.

Figure 1. Percentage of subjects in each quartile at base line and at follow-up

Table 2. Mean scores of subjects at baseline and at follow-up

Scores (Minimum - Maximum) Baseline

(std deviation)

Minimum – Maximum obtained

scores

Follow-up (std deviation)

Minimum – Maximum obtained scores

Mean total scores (22 – 92 ) 53.08 (9.054) 38 - 76 75.45 (5.671) 64 – 87

Mean knowledge score ( 9 – 45) 26.45 (3.059) 20 - 33 42.67 (1.332) 39 – 45

Mean Attitude score (7 – 25) 14.71 (3.332) 10 - 22 19.34 (2.66) 15 – 25

Mean behavior score ( 6 – 22 ) 12.69 (4.798) 5 - 20 13.44 (3.553) 5 – 22

Table 3. Outcome of paired ‘t’ test applied to the mean scores at baseline and follow-up

Difference in mean scores of post intervention to pre-intervention

Mean Std.

deviation Std. error

mean

95%confidence Interval of the Difference Sig.

(2-tailed) Lower Upper

Total 22.372 6.940 .748 20.884 23.860 .000

Knowledge domain 16.221 3.081 .332 15.560 16.881 .000

Attitude domain 4.628 3.620 .390 3.852 5.404 .000

Behavior domain .756 5.653 .610 -.456 1.968 .218

Cancer and Oncology Research 2(4): 43-50, 2014 47

Statistically significant differences were seen in knowledge attitude and total score between pre and post intervention. . Improvement in the attitude was significant (p = 0.000) which was evident in their responses of stopping smoking in public places (51.2%) and their decision to enroll in the tobacco cessation program(33.7%). However, the same was not true for behavior. Improvement in behavior was significant in 20 – 25 year old group, in subjects with

smoked form of tobacco use and in subjects who utilized dental health care services more than once in year (table 4). Pearson correlation analysis revealed that correlation between knowledge and attitude domains was positive and statistically significant, but there was no statistical correlation between knowledge and behavior domains. Correlation between attitude and behavior domains was negative and statistically significant (Table 5).

Table 4. Stratified analysis of improvement in all domain with respect to socio-demographic variables

Significance (2 tailed) in paired ‘t’ test

Variables Stratification Total score Knowledge domain Attitude domain Behavior domain

Gender Male 0.000 0.000 0.000 0.524

Female 0.000 0.000 0.000 0.060

Age

20-25 yrs 0.000 0.000 0.012 0.034

26-30 yrs 0.000 0.000 0.000 0.800

31-35 yrs 0.000 0.000 0.000 0.636

Education Literate 0.000 0.000 0.000 0.044

Illiterate 0.000 0.000 0.000 0.497

Occupation Employed 0.000 0.000 0.000 0.773

Unemployed 0.000 0.000 0.000 0.173

Duration of habit

1-5 years 0.000 0.000 0.000 0.097

6-10 years 0.000 0.000 0.000 0.625

>10 years 0.000 0.000 0.000 0.740

Type of tobacco use

Smoked 0.000 0.000 0.000 0.015

Smokeless 0.000 0.000 0.000 0.776

Dental health service utilization

< 1 time in a year 0.000 0.000 0.000 0.570

> 1 times in a year 0.000 0.000 0.006 0.002

Table 5. Correlation of improvement in the scores of knowledge, attitude, behavior, and in total scores

Percentile difference

in Total score Percentile difference Knowledge domain

Percentile difference in Attitude domain

Percentile difference in Behavior domain

Percentile difference in Total score

Pearson Correlation 1 .721** .831** -.158

Sig. (2-tailed) .000 .000 .146

Percentile difference Knowledge domain

Pearson Correlation .721** 1 .298** -.031

Sig. (2-tailed) .000 .005 .775

Percentile difference in Attitude domain

Pearson Correlation .831** .298** 1 -.258*

Sig. (2-tailed) .000 .005 .017

Percentile difference in Behavior domain

Pearson Correlation -.158 -.031 -.258* 1

Sig. (2-tailed) .146 .775 .017

**. Correlation is significant at the 0.01 level (2-tailed). *. Correlation is significant at the 0.05 level (2-tailed).

48 “Effectiveness of Health Belief Model in Motivating for Tobacco Cessation and to Improving Knowledge, Attitude and Behavior of Tobacco Users”

4. Discussions The villages covered by outreach dental health units of

MS Ramaiah Dental College have farming and sericulture as the predominant occupation. Tobacco use is an integral part of the socio-cultural background. As per the statistics, 20-30% of the patients visiting these outreach centers are current tobacco users. This gives the dental health personnel numerous opportunities to curb the tobacco related diseases. Hence the study was carried out at these outreach centers. Studies have shown that brief medical advice in Primary Health Center is effective in promoting smoking cessation up to 0.5 - 2% (58). Various models are proposed in the literature among which Health Belief Model (HBM) shown promising results. HBM was chosen in the present study for following reasons: (27-30)

1. It is applicable for interpersonal approaches. 2. A good model for addressing problem behaviors that

evoke health concerns. 3. A popular model applied especially in issues

focusing on patient compliance and preventive health care practices.

4. It addresses the relationship between a person’s beliefs and behaviors.

Use of audio visual aids enhances the effectiveness of Health education. They help to simplify unfamiliar concepts; bring about understanding where words fail; reinforce learning by appealing to more than one sense, and provide a dynamic way of avoiding monotony. With this background, health education material in the form of video presentation and leaflets were developed and used in the present study. Leaflets also used for reinforcement and as cues to action.

Current tobacco users with age between 20-35 years were enrolled in the present study. The reasons for considering this age group were:

1. Young adults assume more responsibility to quit habits (31).

2. No severe adverse effects would have occurred due to tobacco use by this age (32) and chance of recovery is more at this age.

3. Addiction to tobacco would be at lower level and hence more are the chances of quitting the habit (33).

4. 50% of current tobacco users are adults (1). 5. In the past three decades there has been a 60%

increase in oral cancer in adults under the age 40 (34).

The follow-up period of two months was fixed with the intention of enrolling the willing to quit subjects into cessation program at the earliest. As per literature research, there were no validated tools in Kannada language to assess the effectiveness of health education. Hence, a tool to assess knowledge, attitude, and behavior towards tobacco use was developed and the tool was subjected to validation procedures and pretested before the actual study began.

Female subjects were participated more compared to males; this could be due to the fact that females tend to take

better care of their oral health than males and are more likely to have regular dental check-ups,(35) primarily due to gender-specific social norms. Studies have also shown that females are more conscious about their teeth when it comes to esthetics (36). Most of the female subjects were homemakers and could visit the dental health service settings as these dental settings work during daytime. Most of the subjects were from lower education qualification and lower socio-economic back ground which is in conformity with the reports of WHO (37, 38). Minimal educational facilities and occupational opportunities could be attributed to low educational qualification and socio-economic status. Majority of the subjects were used smokeless form of tobacco (table 1). This skewed distribution could be attributed to socio-cultural reasons and to predominant female subjects. Utilization of dental health services was less among smokers compared to non-smokers was in conformity to the study reported by LA Mucci et al (39) though particular reason for this behavior was not studied. Lower utilization of dental health services observed in subjects could be attributed to lower education qualification, lower socioeconomic status and the rural background, which are proven socio-demographic determinants for utilization of dental health services as per WHO report (40).

Stratified analysis of effectiveness of health education in improving mean scores of all the domains and total scores (table 4) showed health education based on health belief model was effective in improving knowledge and attitude of all the subjects irrespective of the socio-demographic variables. This signifies the effectiveness of Health Belief Model in influencing the knowledge and attitude of tobacco users. This also could be due to repeated reinforcement and cue to action in the form of leaflets which were delivered and instructed to fix at the places where subjects see more often which supports the conclusion of systematic review done by Christine J et al.2001 McPherson et al 2008 (41, 42).

In the behavior domain, it was effective in subjects aged between 20-25 years, literate, smokers, and those utilizing dental health care services more than once in a year. Significant improvement in younger age group proved the fact that young people assume responsibility for learning and maintaining health-related attitudes and behavior (31). Literate subjects were observed to have better improvement in behaviors than illiterates which also has been shown in the Japanese population and in Greek adults (43, 44). In the present study, health education was effective in improving smokers’ behavior and was not effective in smokeless form of tobacco users, which is in contrast to the results of studies conducted in the past, where authors observed smokers to be more resistant to abstinence than smokeless tobacco users (45). The contradictory results could be due to lesser number of smokers enrolled in the present study and 14 of 18 smokers were literates and 4 were illiterates. Higher literacy rate could have influenced the results. It was also observed that health education was effective in subjects who utilized dental health services more than once in a year. On further

Cancer and Oncology Research 2(4): 43-50, 2014 49

stratified analysis, it was found that literates and younger age group utilized the dental health services more than once in a year and this could be responsible for the significant improvement in the behavior. This observation reflects the fact that educated and younger adults utilize the dental health services more compared to uneducated and older people.

Health education provided was conceptually built on a sound scientific model, which was the main strength of the study. Leaflets were modified according to the cultural sensibilities and education level of the target population by conducting repeated discussions. Questionnaire tool used in the present study was validated before using in the main study. The limitation of the study is that we included only those subjects visiting dental health centers therefore, we recommend to conduct the study on a general population with larger sample and longer duration. The major conclusions from the study are:

1. Health education based on Health Belief Model was effective in improving knowledge and attitude of the tobacco users towards tobacco use.

2. Health Belief Model is effective in improving behaviors of younger subjects, literates, smokers and subjects utilizing the dental health services more than once in year.

3. Leaflets could be used as cue to action in changing the attitude of tobacco users towards tobacco use.

REFERENCES [1] Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D

(2011). Global Cancer Statistics CA Cancer J Clin;61:69–90.

[2] Guest Editorial (2005). Strengthening the prevention of oral cancer: the WHO perspective. Community Dent Oral Epidemiol; 33:397–9.

[3] National Commission on Macroeconomics and Health, Ministry of Health & Family Welfare, Government of India, New Delhi, September 2005, NCMH Background Papers Burden of Disease in India, Shree Om Enterprises Pvt. Ltd. (Online) September 2005. Available from: URL: http://www.who.int/macrohealth/action/Report%20of%20the %20National%20Commission.pdf.

[4] World Health Organization WHO framework convention on tobacco control, WHO Document Production Services, Geneva, Switzerland. (Online) 2003. Available from: URL: http://whqlibdoc.who.int/publications/2003/9241591013.pdf.

[5] Mason J (2005). Concepts in Dental Public Health. 2nd ed. USA Lippincott Williams and Wilkins: 139 – 158.

[6] Pine C, Harris R (2007). Community Oral Health. .2nd ed. United Kingdom: Quitessence Publishing Co.Ltd;. p. 310

[7] Pine CM, McGoldrick PM (2000). An intervention programme to establish regular tooth-brushing: understanding parents' beliefs and motivating children. Int Dent J.; Suppl Creating A Successful:312-23.

[8] Nakazono TT. P.L. Davidson PL, Andersen RM (1997). Oral

health beliefs in diverse populations, Adv Dent Res ll(2):235-244.

[9] Martin GC, Brown JP, Eifler CW, Houston GD (1999) Oral leukoplakia status six weeks after cessation of smokeless tobacco use. J Am Dent Assoc. 130(7):945-54.

[10] World Health Organisation. Health research methodology- A Guide for Training in Research Methods. 2nd ed. Manila: WHO; 2001 (Online). Available from: URL: http://www.wpro.who.int/publications/docs/Health_research _edited.pdf

[11] Abrahamson JH(1974) Survey Methods in Community Medicine. Edinburgh: Churchill Livingstone: p 111-117.

[12] Greco LD, Walop W (1987) Questionnaire development: 1. Formulation, CMAJ, 136: 583-85.

[13] Greco LD, Walop W, McCarthy RH (1987) Questionnaire development: 2. Validity and reliability. CMAJ, 136;699-700.

[14] Walop W, Greco LD, Eastridge L, Marchand B, Szentveri K (1987) Questionnaire development: 4. Preparation for analysis. CMAJ 136;927-928.

[15] Greco LD, Walop W (1987) Questionnaire development: 5. The pretest. CMAJ 136: 1025-26.

[16] Suri S, Verma N. Questionnaire Validation Made Easy (2010) European Journal of Scientific Research 46(2);172-178.

[17] mapi institute- linguistic validation [online] 2011 [cited 2011 23 Jan]. Available from: http://www.mapi-institute.com/linguistic/validation.

[18] Gluck, GM, Morganstein, WM (2003) Jong's community dental health. 5th ed. St. Louis, Mo.: Mosby; 514 p. ISBN/ISSN:0323014674.

[19] Pushpanjali K, Piddennavar R, Malu M (2011) The art and science of questionnaire design. JIPHD;2011(18):154-8.

[20] Kumar N, Shekhar C, Kumar P, Kundu AS (2007) Kuppuswamy‘s Socioeconomic Status Scale-Updating for 2007. Indian Journal of Pediatrics 74: 1131-32.

[21] Agarwal AK (January 2008) Social Classification: The Need to Update in the Present Scenario. Indian Journal of Community Medicine 33(1):50-51.

[22] Psychological Operations/Warfare Leaflets [Online]. 2010 Mar 22.available from: URL: http://www.psywarrior.com/le aflet2.html.

[23] Guidance concerning consultations with target patient groups for the package leaflet. Article 59(3) and 61(1) of Directive 2001/83/EC as amended by Directive 2004/27/EC, May 2006 [Online]. Available from: URL: http://ec.europa.eu/health/files/eudralex/vol-2/c/user_consult ation_200605_en.pdf

[24] Iddo Gal, Ayelet Prigat (Dec 2004) Why organizations continue to create patient information leaflets with readability and usability problems: an exploratory study. Health Education Research Theory & Practice 20(4); 485–493.

[25] Lewis M A, Newton J T (2006) Provision of effective information An evaluation of the quality of commercially

50 “Effectiveness of Health Belief Model in Motivating for Tobacco Cessation and to Improving Knowledge, Attitude and Behavior of Tobacco Users”

produced patient information leaflets. Br Dent J 201: 114-117.

[26] Schmitz JM, Spiga R, Rhoades HM, Fuentes F, Grabowski J (1999) Smoking cessation in women with cardiac risk: a comparative study of two theoretically based therapies. Nicotine Tob Res. 1(1):87-94.

[27] Health Belief Model. 2010 Mar 22 [Online]. Available from: URL: http://msucares.com/health/health/appa1.htm

[28] Evan Burke. The health belief model. 2010 Mar 22 [Online]. Available from: URL: http://currentnursing.com/nursing_theory/health_belief_mod el.html

[29] Hollister MC, Anema MG (2004) Health Behaviour Models and Oral Health: A Review. J Dent Hyg 78(3):1-8.

[30] Kathy A. DeBarr (2004) A Review of Current Health Education Theories . CJHP 2(1):74-87.

[31] Yazdani R, Miira, Vehkalahti M, Nouri M, Murtomma H (2009) School-based education to improve oral cleanliness and gingival health in adolescents in Tehran. Int J Paediatr Dent 19(4):274–281.

[32] Croucher R, Pau AKH, Jerreat M, Begum S, Marcenes W (2003) Oral Health of Bangladeshi Women Tobacco-with-paan Uses and Self-reported Oral Pain Following Tobacco Cessation. J Public Health Dent. 63(4):235-9.

[33] Vasileios M, Eleni MH (2010) Physical and psychological dependence in Greek: an epidemiological study. Oral Health Prev Dent 8:33-39.

[34] Priebe SL, Aleksejuniene J, Dharamsi S, Zed C (2008) Oral cancer and cultural factors in Asia. Can J Dent Hygiene 42(6):291-5.

[35] Gili R, Samorodnitzky-Naveh, Selly B, Geiger, Levin L (2007) Patients‘ satisfaction with dental esthetics. J Am Dent Assoc 138:805-808.

[36] Levy D, Clark C, Steven M, Jay D, Shulman, Maupomé G

(2004) Perceptions of desirable tooth color among parents, dentists and children. J Am Dent Assoc 135:595-604.

[37] Steele JG, Treasure E, Pitts NB, Morris, Bradnock G (2000) Total tooth loss in the United Kingdom in1998 and implications for the future. Br Dent J, 189(11):598-603.

[38] Actions on social determinants of health: Learning from previous experiences. A background paper prepared for the commission on social determinants of health. 2005 Mar [Online]. Available from: URL: http://www.who.int/social_d eterminants/resources/action_sd.pdf.

[39] Mucci LA, Brooks DR (2001) Lower use of dental services among long term cigarette smokers, J Epidemiol Community Health 55:389–393.

[40] The world health report 2003- Shaping the future, World Health Organization [Online]. Available from: URL: http://www.who.int/whr/2003/en/whr03_en.pdf.

[41] Christine J, McPherson, Irene J, Higginson, Hearn J (2001) Effective methods of giving information in cancer: a systematic literature review of randomized controlled trials. J Public Health Medicine 23(3); 227-234

[42] Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation (Review). The Cochrane collaboration:1- 25 2008[Online]. Available from: URL: http://www.thecochranelibrary.com/userfiles/ccoch/file/Worl d%20No%20Tobacco%20Day/CD001292.pdf

[43] Anzai Y, Ohkubo T, Nishino Y, Tsuji I, Hisamichi (2000) Relationship between health practices and education level in the rural Japanese population. J Epidemiol. 10(3):149-56.

[44] Koletsi-Kounari H, Tzavara C, Tountas Y (2011) Health-related lifestyle behaviors, socio-demographic characteristics and use of dental health services in Greek adults. Community Dent Health. 28(1):47-52.

[45] Hajek P, Stead LF, West R, Jarvis M, Lancaster T. Relapse prevention interventions for smoking cessation (Review). 1- 49: The Cochrane collaboration 2009[Online]. Available from: URL: http://www.thecochranelibrary.com/userfiles/cc och/file/World%20No%20Tobacco%20Day/CD003999.pdf.

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