THE EFFECT OF PEER-TO-PEER HEALTH EDUCATION ON THE

PERCEPTION OF THE SMOKING OUTCOMES AMONG

. ADOLESCENTS IN KUCHING, SARAWAK, 2007.

JEFFERY ANAK STEPHEN

A thesis submitted in fulfillment of the requirements for the Masters of Public

Health (Health Promotion).

Faculty of Medicine and Health Sciences

UNIVERSITI MALAYSIA SARAWAK

2009

DEDICATION

To my wife, Kuang, and my two little princesses, Samantha Grace and Eleora Hanna, for their

loving patience and limitless support.

iii

ACKNOWLEGDEMENTS

Warm thanks to many individuals, both directly and indirectly, influenced me and helped

me to complete this project. Of course, in particular I would like to thank my supervisor,

Professor Madya Dr. Siti Raudzah Ghazali for her guidance, patience, advice and encouragement

throughout the project.

Many, many thanks to Tan Sri Datu Dr. Mohd. Taha b. Arif, Professor Dr. Mohd. Syafiq

b. Abdullah, Professor Dr. Mohd. Raili b. Suhaili and Professor Madya Dr. Kamaruddin b. Bakar

for their positive comments and guidance; and to Professor Dr. Nooriah bt. Mohd Salleh and

Mdm. Cheah Whye Lian for their assistance in statistical analysis.

Many thanks to Dr. Haji Jamail b. Haji Muhi who is the Kuching Division Health

Officer, for allowing me to co-operate with the Unit Promosi Kesihatan in completing my

project; and to Mdm Pises Busu and Mr. Cairol b. Baseri for helping me with the data collection.

I also want to acknowledge the school principals, teachers and students of SMK Padawan, SMK

Lundu, Kpg. Keranji and Kpg. Haji Baki for their involvement in the project.

iv

TABLE OF CONTENTS

DECLARATION

DEDICATION

ACKNOWLEDGEMENTS

TABLE OF CONTENTS

APPENDIX

LIST OF TABLES

LIST OF FIGURES

ABBREVIATIONS

ABSTRACT

AB STRAK

CHAPTER 1. INTRODUCTION AND LITERATURE REVIEW

1.1. Introduction.

1.1.1. Purpose of the study.

1.1.2. Background of the study area.

1.1.3. Significance of the study.

1.2. Literature review.

1.2.1. Introduction.

1.2.2. Adolescent and the theory of perception. 1.2.3. Adolescent and perception of smoking outcomes.

1.2.4. Defining "peer" and "peer-to-peer health education".

1.2.5. The impact of peer-to-peer health education on adolescents in relation to smoking. 1.2.6. Conclusion.

1.3. Statement of the problem.

1.4. Research Objectives.

1.4.1. General Objectives.

1.4.2. Specific Objectives.

1.5. Research Hypotheses.

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CHAPTER 2. MATERIALS AND METHODOLOGY

2.1. Methodology.

2.1.1. Research design.

2.1.2. Sample population.

2.1.3. Sampling method.

2.1.3.1. Inclusion and exclusion criteria.

2.1.4. Sample size calculation.

2.1.5. Procedures and data collection. 2.1.5.1. Ethical Approval.

2.1.5.2. Description of the implementation of the programme.

2.1.5.3. Description of the intervention programme.

2.1.5.4. Assessing the intervention programme. 2.2. Materials.

2.2.1. Questionnaire.

2.2.1.1. Section A: Demography.

2.2.1.2. Section B: Smoking Outcomes Perception Scale (SOPS).

2.2.2. Pilot study.

2.3. Data entry and analysis. 2.4. Operational definitions.

CHAPTER 3. RESULTS

3.0. Introduction.

3.1. Analysis of SOPS.

3.2. Descriptive analysis of the characteristic profiles of the participants. 3.2.1. Age.

3.2.2. Gender.

3.2.3. Ethnicity and Religion.

3.2.4. Other characteristics.

3.2.5. Preliminary data analysis

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3.3. Evaluation analysis of peer-to-peer health education programme with respect to the research

questions and hypotheses.

3.3.1. Research Question #1: Do adolescents change their perception of smoking outcomes

after attending peer-to-peer health education?

3.3.2. Research Question #2: Do male and female adolescents differ in their perception of

smoking outcomes after attending peer-to-peer health education? 3.3.3. Research Question #3: Do Malay and Dayak adolescents differ in their perception of

smoking outcomes after attending peer-to-peer health education?

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45

48

52

CHAPTER 4. DISCUSSION, LIMITATIONS AND CONCLUSION

4.1. Discussion. 56

4.2. Limitations. 62

4.3. Conclusion. 67

CHAPTER 5. IMPLICATIONS AND RECOMMENDATIONS

5.1. Implications. 68

5.2. Recommendations. 70

BIBLOGRAPHY 72

vii

APPENDIX

APPENDIX A: Approval letter from the Faculty's Ethic Committee 99

APPENDIX B: Approval letter from the Divisional Health Officer of Kuching Division 101

APPENDIX C: Questionnaire 103

viii

LIST OF TABLES

Table 3.1 Factor analysis of the smoking outcomes perception with principle component

extraction, Varimax rotation and eigenvalue of 2, conducted among twenty local

adolescents. 36

Table 3.2 Cronbach's alpha and test-retest coefficients for the smoking outcome perception

scale conducted among twenty local adolescents. 37

Table 3.3 Number (percentages) of participants who were attended the workshop and eligible for the study. 38

Table 3.4 Characteristic profiles of the participants between the intervention and the control

groups. 42

Table 3.5 The median scores before and after the intervention sessions and statistical results for

both groups. 47

Table 3.6 The median scores before and after the intervention sessions, and statistical results for

male and female adolescents in the intervention group. 50

Table 3.7 The median scores before and after the intervention sessions, and statistical results for

male and female adolescents in the control group. 51

Table 3.8 The median scores before and after the intervention sessions, and statistical results for

the Malay and the Dayak adolescents in the intervention group. 54

Table 3.9 The median scores before and after the intervention sessions, and statistical results for

the Malay and the Dayak adolescents in the control group. 55

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LIST OF FIGURES

Fig 1.1 Conceptual framework related between perception, smoking outcomes and health

education.

Fig 2.1 Map of Kuching division and the four locations that involved in the current study.

8

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Fig 2.2 Flowchart of Research Methodology. 28

X

ABBREVIATIONS

CDC Centers for Disease Control and Prevention

C. I. Confidence Interval

GMOS General Medical Outcomes Perception Subscale

IQR Inter-quartile range

MOH Ministry of Health, Malaysia

PROSTAR Program Sihat Tanpa AIDS untuk Remaja

PWOS Physical Well-being Outcomes Perception Subscale

SOPS Smoking Outcome Perception Scale

UK United Kingdom

UNAIDS Joint United Nations Programme on HIV/AIDS

USDHHS U. S. Department of Health and Human Services

WPRO Western Pacific Region Office

WHO World Health Organization

xz chi-squared test

d. f. degree of freedom

M Mean

Mdn Median

n Sample size

p Probability value

r Effect size

SD Standard deviation

T Wilcoxon Signed Rank T test

U Mann-Whitney U test

X1

ABSTRACT

THE EFFECT OF PEER-TO-PEER HEALTH EDUCATION ON THE PERCEPTION OF THE SMOKING OUTCOMES AMONG ADOLESCENTS IN KUCHING, SARAWAK, 2007.

Jeffery anak Stephen

i The main objective of the study was to examine whether the peer-to-peer health education was

effective in changing the perception of the smoking outcomes among local adolescents in

Kuching, Sarawak This study adopted a quasi-experimental design with 55 participants in

intervention group and 41 participants in the control group. The intervention group was subjected

to one session of peer-to-peer education. Baseline data for smoking outcomes was collected

before the intervention and the data was collected one day after the intervention by using

Smoking Outcome Perception Scale (SOPS)'Nonparametric analyses of the scores showed that

the peer-to-peer health education significantly changed the smoking outcomes perception among

the participants in the intervention group (Wilcoxon Signed Rank test, p< . 05) with significant

change in the scale scores observed among the males (Wilcoxon Signed Rank test, p< . 05

participants of the Dayak ethnicity showed significant change in the smoking outcomes

perceptions after they attended the peer-to-peer health education session (Wilcoxon Signed Rank

test, p< . 05). Neither the females nor those of the Malay ethnicity showed any significant change

in in the smoking outcomes perception (Wilcoxon Signed Rank test, p> . 05). These modest

findings lend credence that peer-to-peer health education is effective in changing the smoking

outcomes perception among local adolescents with diverse cultural background.; %

xii

ABSTRAK

KESAN PENDIDIKAN KESIHATAN OLEH RAKAN KEPADA RAKAN SEBAYA KE ATAS PERSEPSI KESAN-KESAN MEROKOK DI KALANGAN REMAJA DI

KUCHING, SARAWAK, 2007.

Jeffery anak Stephen

Objektif utama kajian ini ialah untuk mengkaji sama ada pendidikan kesihatan oleh rakan kepada

rakan sebaya dapat mengubah persepsi kesan-kesan merokok di kalangan remaja tempatan di

Kuching, Sarawak. Rekabentuk kuasi-eksperimen dijalankan dengan melibatkan 55 orang

peserta di dalam kumpulan rawatan dan 41 orang peserta di dalam kumpulan kawalan. Satu sesi

pendidikan kesihatan oleh rakan kepada rakan sebaya telah dijalankan ke atas kumplan rawatan.

Data dasar untuk persepsi kesan-kesan merokok yang mana diukur oleh skala persepsi kesan-

kesan merokok telah diambil sebelum sesi intervensi dan dengan menggunakan skala yang sama,

data pasca-intervensi diambil sehari selepas sesi intervensi. Ujian tak berparameter untuk skor-

skor telah menunjukkan pendidikan kesihatan oleh rakan kepada rakan sebaya secara

signifikannya telah mengubah persepsi kesan-kesan merokok di kalangan peserta di dalam

kumpulan intervensi (Ujian pangkat bertanda Wilcoxon, p< . 05) dengan signifikan perubahan

skor di kalangan peserta lelaki (Ujian pangkat bertanda Wilcoxon, p< . 05). Peserta berketurunan

Dayak juga telah menunjukkan perubahan signifikan di dalam persepsi kesan-kesan merokok

selepas mereka menghadiri pendidikan kesihatan oleh rakan kepada rakan sebaya (Ujian pangkat

bertanda Wilcoxon, p< . 05). Tiada peserta perempuan mahupun peserta berketurunan Melayu

menunjukkan perubahan signifikan di dalam persepsi kesan-kesan merokok (Ujian pangkat

bertanda Wilcoxon, p> . 05). Hasil keputusan ini telah membuktikan kebenaran bahawa

pendidikan kesihatan oleh rakan kepada rakan sebaya adalah efektif dalam mengubah persepsi

kesan-kesan merokok di kalangan remaja tempatan yang mempunyai latar-belakang pelbagai

budaya.

X111

CHAPTER 1

INTRODUCTION AND LITERATURE REVIEW

1.1. Introduction

According to the recent statistics, smoking accounts for one out of every five

deaths in Malaysia and these numbers are expected to triple over the next three decades

from 10,000 in 1998 to 30,000 by the year 2030 (Ministry Of Health Malaysia [MOH],

2003). About 50 teenagers below the age of 18 start smoking everyday (Western Pacific

Region Office [WPRO], 2002) and usually they start by experimenting it first (Jarvis,

2004; Klein, 2006). Several studies showed that the average age of start smoking is

around 13 to 15 years old (Maziak & Mzayek, 2000; Hammond, 2000). In reaction to the

alarming rates of smoking, increases in anti-smoking literature and campaigns have

emerged to educate the public, primarily targeting the adolescents about the severe

dangers of cigarette smoking. Schools have been suggested to be a platform for health

promotion programmes for the students because this is where the students are easily

accessible (Centers for Disease Control and Prevention [CDC], 1994; CDC, 1999;

Bandura, 2004). Hence, many smoking prevention programs utilizing peer-to-peer health

education approach have been conducted in schools and have been proven effective

(Prince, 1995; Mellanby, Rees & Tripp, 2000; Valente, Hoffman, Ritt-Olson, Lichtman

& Johnson, 2003; Hwang, Yeagley & Petosa, 2004). The application of peer-to-peer

health education approach in a variety of cultural settings such as in Kuching Sarawak,

warranted further research to look into its effectiveness (Paavola, Vartiainen & Puska,

I

2001; Cuijpers, 2002; Scarinci, Robinson, Alfano, Zbikowski & Kiesges, 2002; Ma,

Fang, Tan, Feeley & Thomas, 2003).

1.1.1 Purpose of the study

The purpose of the study was to examine whether the peer-to-peer health

education was effective in changing the perception of smoking outcomes among

adolescents in Kuching, Sarawak. The changes in the perception were measured using

Smoking Outcome Perception Scale (SOPS) before and after the intervention.

1.1.2 Background of the study area

The current study was carried out in Kuching division which consists of three

main subdivisions namely Kuching, Bau and Lundu. There are many ethnic groups in

Kuching division. The population comprises Chinese 35%, followed by Malay 34%,

Dayak 27% and others 4% (Sarawak Population Statistic, 2004).

It is estimated that adolescents in Sarawak consist of 19% of the total population

(Sarawak Population Statistic, 2004). The Dayak (consist of Than and Bidayuh ethnic

groups) form the largest adolescent population with 39%, followed by the Malay 24%,

Chinese 23%, and others 13%.

2

1.1.3. Significance of the study

Smoking is no longer confined to adults. Among young teens (aged 13 to 15),

about one in five smoke worldwide (WPRO, 2002). Between 80,000 and 100,000

children worldwide start smoking every day - roughly half of whom live in Asia (WPRO,

2002). Most smokers acquire the habit before the age of 20 (CDC, 2005). In Malaysia, it

has been estimated that smoking prevalence among teenage boys aged 12-18 years was

30% while smoking among girls has doubled from 4.8% in 1996 to 8% in 1999

(Malaysia's Health, 2002). A local survey carried out in Selangor in 1993 showed that

about 16% of the adolescents aged 13-19 years old were smokers (A. Jalal, et al., 1995).

A cross-sectional study in Negeri Sembilan in 2001 revealed about 14% of secondary

school students were smokers (Lee, Paul, Kam & Jagmohni, 2005). The prevalence of

smoking among the male students was higher (26.6%) compared to the female students

(3.1%) (Lee, et al., 2005). In another separate study, almost one third of all students

surveyed have ever smoked cigarettes and about 20% of them were current smokers, with

boys outnumbering the girls (Krishnan, 2003).

The Ministry of Social Development and Urbanization of Sarawak (2005)

conducted a study on tobacco usage among adolescents in Sarawak. Results showed that

the prevalence of smoking among the Sarawakian adolescents was 36.5% with high

percentages of male smokers, 30.9% compared to the female smokers, 5.6%. This finding

is consistent with the earlier documented reports (Malaysia's Health, 2002; Krishnan,

2003). The mean age of start smoking among the Sarawakian adolescents was 13 years

old which was consistent with other findings (Francoa, et al., 2004; Rius, Fernandez,

Schiaffino & Rodriguez-Artalejo, 2004). Based on ethnicity, the Orang Ulu ethnic group

3

has the highest smoking prevalence (47.2%) followed by the Ibans (40.7%), Melanau

(39.9%), Bidayuh (39%), Malays (37.1%) and Chinese (23.8%) (Ministry of Social

Development and Urbanization of Sarawak, 2005).

The above statistics showed the magnitude of smoking among adolescents in

Malaysia especially in Sarawak which signify the need to identify effective health

promotion interventions. Previous studies have demonstrated the effectiveness of health

education (e. g. Hanewinkel & Aßhauer, 2004; Campbell, et al., 2008). However, little is

known about the effect of peer-to-peer health education on the perception of smoking

outcomes among local adolescents in Kuching. If the predictors of smoking uptake are

different across gender (Brown, Teufel, Birch, Izenberg & Lyness, 2006) and ethnic

groups (Robinson, Kiesges, Zbikowski & Glaser, 1997), then it would be expected that

response to the intervention would also vary. By examining the effect of peer-to-peer

health education, it provides some information to the health personnel in developing and

implementing an effective smoking prevention programme targeted for the local

adolescents.

4

1.2. Literature Review

1.2.1. Introduction

Approximately one in every five people in the world is an adolescent (United

Nations Children's Fund, 2000; Gubhaju, 2002). Adolescent is defined as a person

between 10 and 19 years of age (World Health Organization [WHO], 1998). Despite

being thought to be healthy (WHO, 1998), many of them die prematurely because they

decided to smoke cigarettes (CDC, 2006).

Cigarette smoking almost exclusively starts during adolescence (U. S. Department

of Health and Human Services [USDHHS], 1994; World Bank, 1999) and progression to

become established smokers increases over time as the adolescents progress into

adulthood (Orlando, Tucker, Ellickson & Klein, 2004). Smoking prevention is seen as an

important way of reducing smoking incidence rates among adolescents (Tennesen, 2002).

It is because most adolescents are unaware of the possible health outcomes to which they

are exposed to (Slovic, 1998).

The following reviews focus on: a) adolescent and the theory of perception; b)

adolescent and perception of smoking outcomes; c) defining "peer" and "peer-to-peer

health education"; and d) the impact of peer-to-peer health education on adolescents in

relation to smoking.

5

1.2.2. Adolescent and the theory of perception.

The word `perceive' is derives from the Latin word `percipere': `per' meaning

`thoroughly' and `capere' meaning `to take' (Meri am-Webster's Collegiate Dictionary,

1993; p. 861). Perception has been conceptualized by cognitivists as a process during

which knowledge or awareness is obtained, it has to undergo the processes of selection,

organization and modifications by the brain of specific input from different sensory

organs (Kail & Wicks-Nelson, 1993). These inputs from the sensory organs include see,

hear, smell, taste and touch. Sensations, in this context, generated by the stimuli have

become immediate and basic experiences (Matlin & Foley, 1992). Stimuli can be

observable or unobservable (Combs, Richards & Richards, 1976 as cited in Bunting,

1988).

Perception functions are seen as a logical inference and a rational between the

sensory input of a stimulus and the conclusion that the brain interpreted (Richeimer,

2006). These functions are also referred to the judgement process (Loewenstein, Weber,

Hsee & Welch, 2001). Ultimately, perception gives rise to belief, whether it is true or

false about the surrounding environment (Yolton, 1962). In this context of study,

inaccurate judgements about smoking outcomes can hurt people. So can inaccurate

beliefs about those judgements. If people's understanding is overestimated, then they

may face impossibly hard choices (e. g. unfamiliar ways to stop smoking, without

adequate information). If people's understanding is underestimated, then they may be

needlessly denied the right to choose.

The concept of perception plays a vital role during adolescence. Adolescence is a

transition stage from childhood to adulthood (Erikson, 1950). The adolescents perceive

6

themselves as who they are as a result of his or her socialization-past (Wright, 1977).

They need to use judgement processes (perception functions) which include integration,

evaluation and re-evaluation of all past childhood experiences and choose those that are

appropriate to become what is known as an ego identity (Erikson, 1950 & 1985). It

coincides with the concept of perception where a person will use selection in choosing

events that need to be emphasized and eventually become part of the knowledge

(Bunting, 1998). Past experiences are seen as stimuli which undergo the process of

rational and logical inference in arriving to the conclusion or beliefs.

The relationship between perception and smoking outcomes can be illustrated in a

simple linear model (see Fig. 1.1). The inputs or stimuli can be interpreted as seeing

friends or family members smoking, hearing the benefits and/or harmful effects of

smoking, taste of smoking, smelling the cigarette smoke and touching the cigarette.

These stimuli become immediate events and experiences to the individual. These inputs

then undergo a process of rational and logical inference (the perception functions) to

come to some conclusions or beliefs towards the cigarette smoking whether it is good or

bad. It is during the process of logical inference the information about the harmful effects

(short-term and long-term) of smoking can be emphasized and imbedded through health

education.

7

Figure 1.1.

Conceptual framework between perception, smoking outcomes and health education.

STIMULUS See friends/parents smoking

Hear about benefits/harmful effects of smoking Taste of cigarette

Smell of cigarette smoke Touch of cigarette

Immediate events and experiences

Perception

1 Beliefs

(smoking outcomes)

4

Health Education

Short-term and long-term

health hazards due to smoking

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1.2.3. Adolescent and perception of smoking outcomes.

Perceived outcomes play an important role in many models of substance use

(Hine, Summers, Tilleczek & Lewko, 1997; Petraitis, Flay & Miller, 1995; Carvajal,

Hanson, Downing, Coyle & Pederson, 2004; Wahl, Turner, Mermelstein & Flay, 2005)

and have been associated with smoking in adolescents (Anderson, Pollak & Wetter,

2002). Bandura (2004) defined the perceived outcomes as "about the expected costs and

benefits for different health habits" (p. 144). In addition, the values placed on those

outcomes may affect the health behaviour (Bandura, 2004).

Perception of smoking outcomes are influenced by two types of cognitive

judgments: that is judgment about the probability of smoking outcomes and judgment

about the desirability of these outcomes (Hine, Tilleczek, Lewko, McKenzie-Richer &

Perreault, 2005). If the outcome seems positive or beneficial to the individual, he or she

may then intend to or actually participate in a particular behaviour. The opposite can also

be stated if the behaviour is thought to be negative or non-beneficial.

The relationship between perception and unhealthy risk-taking behaviours among

adolescents such as smoking, drug use, unprotected sex, alcohol and unsafe driving has

been widely studied. For example, in a comparative study by Cohn, Macfarlane, Yanez &

Imai (1995), adolescents aged between 13 to 18 years perceive such behaviours like

cigarette smoking, drink alcohol, sniff glue, not using seat belts and use of cocaine were

less harmful to them whether they take it experimentally, occasionally or frequently

compared to their parents' perceptions. These differences are probably due to the fact that

adolescents and adults might differ in identifying possible consequences of an option

chosen and place different values of possible consequences with respect to either positive

9

or negative consequences (Furby & Beyth-Marom, 1992). Moreover, there is

considerable evidence of adults seeing themselves as less at risk than others (Quadrel,

Fischhoff, & Davis, 1993).

Smoking outcomes perception in adolescents has been associated with smoking in

the future because they believed that they are invulnerable (Quadrel et al., 1993; Slovic,

1998; Spijkerman, Van Den Eijnden & Engels, 2007). In a cross-sectional study by

Halpern-Felsher, Biehl, Kropp and Rubinstein (2004), adolescents who smoked cigarette

and intend to smoke in the future perceive smoking-related risks to be less likely to occur.

Moreover, they believed that smoking-related benefits are more likely to occur. In

contrast, those non-smoker adolescents with no intention to smoke perceived otherwise.

Studies have demonstrated that the smokers are less likely to be concerned with

the health outcomes/consequences compared to the non-smokers (Mittelmark, et al.,

1987; Weinstein, 1999; Hine et al., 2005). Adolescent smokers perceived that smoking-

related risks were less likely to occur. They also perceived smoking-related benefits as

being more likely to occur (Halpern-Felsher, et al. 2004). Therefore, adolescents who

perceived that smoking has social benefits or serve functional values to them are more

likely to smoke (Epstein, Griffin & Botvin, 2000). In Lundborg and Lindgren study

(2004), there were differentials in risk perceptions in relation to smoking outcomes

among adolescents. However, their study did not discuss further the differences between

the genders and ethnic groups. They also did not suggest any intervention programme to

change the incorrect perceptions. These are the gaps in knowledge that the current study

attempt to answer in relation to local adolescents.

10

Studies have demonstrated that perception on smoking outcomes have been

greatly influenced by two factors that is, gender and ethnicity (Finucane, Slovic, Mertz,

Flynn & Satterfield, 2000; Brown, Teufel, Birch, Izenberg, & Lyness, 2006). For

example, in a cross-sectional study conducted by Ma and colleagues (2003), males were

less likely to perceive risk outcome towards tobacco usage compared to females. The

gender difference is greatly influence by the ethnicity itself and this could be related to

differences of beliefs about gender roles (Kaholokula, Braun, Kana'iaupuni, Grandinetti

& Chang, 2006), the social acceptance of smoking by others of their own ethnic group

(Bush, White, Kai, Rankin & Bhopal, 2003), influence by peer groups (Mermelstein &

The Tobacco Control Network Writing Group, 1999; Kobus, 2003), and family members

(Shakib, et al., 2003). However, these studies have not addressed the needs of the peer-to-

peer health education programme as part of its health promotion strategy in changing

perception on smoking outcomes.

Although Dalton and colleagues (1999) argued that teaching the negative

consequences of cigarette smoking is less likely to change the adolescents' intent to

smoke, health education based on perception of smoking outcomes is still relevant to be

used as part of health promotion activity in efforts to prevent smoking behavior (CDC,

1994). By providing correct information on the health consequences due to smoking, the

adolescents develop some degree of "skills and efficacy beliefs that enable them to

manage the emotional and social pressures to adopt detrimental health habits" (Bandura,

2004, p. 158). Epstein and colleagues (2000) also support that the prevention efforts

should focus on any means of affecting the perception of smoking outcomes.

11

1.2.4. Defining "peer" and "peer-to-peer health education".

Smoking incidence among adolescents is greatly influenced by peers (USDHHS,

1994; Simons-Morton, Haynie, Crump, Eitel, & Saylor, 2001; Unger, et al., 2002; Kobus,

2003; Arnett, 2007). Being pressured by peers who smoke (Ennett & Bauman, 1993;

Denscombe, 2001) and having peers who are involved in high health-risk behaviours

(Lerner & Galambos, 1998; Prinstein, Boergers & Spirito, 2001) are among many factors

to explain the findings. Peer influence also can be seen as a protective factor to such

health-risk behaviours like cigarette smoking (Maxwell, 2002), which is the basis of the

theoretical concept for the peer-to-peer education programme (Campbell, et al., 2008).

The term `peer' relates to one of equal status with another or that an individual

belongs to the same societal group especially based on age, grade or status (Joint United

Nations Programme on HIV/AIDS [UNAIDS], 1999; Stephenson, et al., 2004). Shiner

(1999) described the term `peer' as close friends, habitual associates or relative strangers

who happen to be involved in the same activity in the same setting.

The peer also reflects either a true peer or near peer (McDonald, Grove & Youth

Advisory Forum Members, 2001). A true peer is a person who is considered a member of

a particular group, both by themselves and by other group members (Larkin, 1998). For

example in Larkin's (1998) study, injecting drug users were recruited and trained to

educate and influence their drug and sex network members about HIV-related

behaviours. A near peer is similar but differs in certain circumstances, for example they

may be a few years older. For example in a study conducted by Sheehan, Dicara,

LeBailly and Christoffel (1999), adolescents between ages 14 and 21 years became peer

12