research article changing smoking behavior of staff at...

Research ArticleChanging Smoking Behavior of Staff at Dr Zainoel AbidinProvincial General Hospital Banda Aceh

Said Usman1 Soekidjo Notoadmodjo2 Kintoko Rochadi1 and Fikarwin Zuska1

1Faculty of Public Health University of North Sumatra Medan 20155 Indonesia2Indonesia Respati University Jakarta 13890 Indonesia

Correspondence should be addressed to Said Usman saidusmanmkesyahoocoid

Received 1 August 2014 Revised 2 October 2014 Accepted 17 November 2014 Published 17 December 2014

Academic Editor Jennifer L Freeman

Copyright copy 2014 Said Usman et al This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Smoking tobacco is a habit of individuals Determinants of smoking behavior are multiple factors both within the individual and inthe social environment around the individual Staff smoking has been an undesirable phenomenon at Dr Zainoel Abidin ProvincialGeneral Hospital in Banda Aceh Health promotion efforts are a strategy that has resulted in behavioral changes with reductions insmoking by staff This action research was designed to analyze changes in smoking behavior of hospital staff The sample for thisresearch was all 152 male staff who were smokers The results of this research showed that Health Promotion Interventions (HPI)consisting of personal empowerment plus social support and advocacy to improve employee knowledge and attitudes influencedstaff to stop or to significantly HPI employed included counseling programs distribution of antismoking leaflets putting upantismoking posters and installation of no smoking signs These HPI proved effective to increase knowledge and create a positiveattitude to nonsmoking that resulted inmajor reductions in smoking by staff when offsite and complete cessation of smoking whilstin the hospital Continuous evaluation monitoring and strengthening of policies banning smoking should be maintained in allhospitals

1 Introduction

11 Background Human behavior is a reflection of variouspsychological tendencies that are based on stimuli fromoutside both intentional and unintentional having eitherpositive responses or negative responses Behavior has threedomains that can be measured namely knowledge attitudesand practices Knowledge and attitudes are passive responseswhereas practice is an active response

Health behavior is a form of stimulus that is relatedto health and sickness One form of unhealthy behavior issmoking tobacco or cigarettes As described in Act number36 of 2009 health is a state of health including physicalmental spiritual and social health which allows everyone tolive productively in a social and economic way Smoking isan individual andor group behavior which is injurious to thehealth of the smoker and also to the health of others throughsecondary smoking so that the individual who smokes can becategorized as unhealthy

Cigarette smoking is a form of behavior that is a mani-festation of specific needs that can be satisfied when a personsmokes Smoking behavior is the action of a personwho suckstobacco smoke into their own mouth and lungs Smokingbehaviour can be observed or measured by looking at thevolume or frequency of smoking of that person [1]

In epidemiology smoking tobacco especially from ciga-rettes is a worldwide health problem The World HealthOrganization (WHO) predicts that by 2020 tobacco-relateddisease will be one of the worldrsquos major health problems andwill cause approximately 84 million deaths every year Theincidence of men smoking in countries with low to middleincomes is very high that is 39 as compared to 35 formenin countries with middle to high incomes Another healthfact is that on average smokers die 13 to 14 years soonerthan nonsmokers Smoking results in macroeconomic lossesIn Indonesia smokers smoke 230 billion cigarettes per yearcosting US$14 billion per year moreover the medical costsor losses due to smoking in Indonesia alone amounted to

Hindawi Publishing CorporationAdvances in Public HealthVolume 2014 Article ID 316274 12 pageshttpdxdoiorg1011552014316274

2 Advances in Public Health

US$185 million per year (WHO 2011) which is 12 (twelve)times greater than the cost of the cigarettes themselves

Smoking can cause harm to health because smoke froma tobacco cigarette contains over 7000 chemicals many ofwhich are very dangerous to health including many whichcan cause cancer especially the three main components ofthe smoke namely nicotine tar and carbon monoxide In2012 theWHO stated that smoking is a cause of cancer heartdisease strokes and lung diseases (including bronchitisemphysema and chronic pulmonary obstruction [CPO])

Various studies have proven that smoking is extremelyharmful to health According to McEwen et al [2] theleading causes of death associated with smoking are cancercardiovascular disease and pulmonary diseases like bron-chitis emphysema that is CPOD and pneumonia Researchat Sanglah General Hospital in Denpasar Bali showedthat amongst patients who sought treatment for pulmonarydiseases 71 of the patients who sought treatment for lungdisease had been exposed to cigarette smoke Of these 14were active smokers 42 were former smokers and the rest15 were passive smokers that is people who lived withsmokers

Some health workers in clinics health centers hospitalsand other health related institutions also smoke Researchby Cofta and Staszewski [3] at the Hospital of the LordrsquosTransfiguration in Poland found that 27 of health carepersonnel were smokers 35 of these were nurses what ismore 82 of them smoked at work The research of Moneeret al [4] at the National Cancer Institute Cairo Egyptfound 20 of health workers were active smokers 5 wereoccasional smokers and the rest 75 were nonsmokers

Research by Nagle et al [5] with nurses at six hospitals inNew South Wales Australia found that knowledge amongstnurses about the damage to health caused by smoking signifi-cantly lowered the habit of smoking whilst working and suchknowledge tended to be influenced by information aboutsmoking bans and awareness to change This indicates thatthe continuous delivery of information to hospital employeesboth medical personnel and others can influence the healthbehavior of the employees concerned in particular it canresult in the employees concerned changing that is reducingtheir smoking behavior

The reasons a person smokes vary a lot A person learnsabout smoking from their environment Initially they observepeople smoking After they try smoking for the first timesome individualsmay feel a desire to smoke again for a varietyof reasons for example to reduce anxiety to lose the feelingof overload and stress from work to feel accepted within aparticular group and for some to relax especially because ofstress from family or other problems

When the smoking habit is already formed social fac-tors play an important role to keep the smoking behaviorgoing According to Kaplan and James [6] the tendencyof individuals to continue to smoke is a phase to sustainthe smoking behavior stage that is a stage in behavior dueto a combination of psychological factors and biologicalmechanisms

Smoking behavior is one type of behavior that can bechanged According to Notoatmodjo [7] change in behavior

can be categorized into three types namely (1) naturalchanges mainly due to changes in the physical environmentor to changes in social cultural or economic activities withrespect to the individual (2) planned change that is changein behavior due to planning by the individual concernedand (3) change due to the willingness for change (readinessfor change) that is changes due to innovations and newprograms that allow individuals to change Changes can berapid or slow depending on each individualrsquos willingnessAccording to various experts behavior can be changed if itis based on strong intentions and a belief that such changesin behavior will be good plus there is strong motivation tochange

Behavior change according to Green [8] is influenced bythree main factors namely (1) predisposing factors that isfactors which more easily affect someonersquos behavior amongstother things knowledge beliefs values traditions and soforth (2) enabling factors that is factors that facilitatebehavior or that enable action and they include tools andinfrastructure or facilities for the behaviors to be done and(3) reinforcing factors (amplifier factors) that is factorsthat encourage or strengthen the occurrence of the behaviorconcerned Even if someone knows and is able to adopthealthy behavior they sometimes do not do so for variousreasons

Smoking behavior can be changed however stoppingsmoking behavior is not an easy thing Results from surveysconducted by the LMMM (LembagaMenanggulangiMasalahMerokok or Foundation for Overcoming Smoking Problems)show that 66 of smokers have tried to quit smoking buthave failed Some failed because they did not know howto stop smoking and some failed because they said theyfound it too hard to concentrate when not smoking Ofthe respondents who successfully quit smoking 76 didso because of awareness itself 16 because of illness and8 because of the demands of their profession according toHelman [9]

Changing the behavior of smoking of health workers orstaff at a hospital is not an easy thing to do Efforts to stopthe smoking habits of staff in hospitals can be done with ahealth education approach In general hospital employeesare individuals with a background of health who alreadyunderstand and know about the impact of smoking tobaccoand cigarettes and the effects of the smoke itself on othersnevertheless it is a fact thatmany healthworkers smoke thusit can be assumed that the approach to change the behaviorof hospital employees to get them to quit their smoking habitwill not be easy But one thing that can be done is to stopthe staff who smoke from smoking in the hospital and itsgrounds

This is supported by Public Health Act number 36 of 2009that makes public places in particular public hospitals NoSmoking Areas (KTR or Kawasan Tanpa Rokok) A hospitalis an institution that provides complete health services toindividuals including in-patient out-patient and emergencyservices One function of a hospital is (health) maintenanceand improvement of individual health through completehealth services according to medical needsThat is a hospitalis a place to get treatment that hopefully does not cause other

Advances in Public Health 3

health issues such as health problems caused by cigarettesmoke A hospital is one place that must be a nonsmokingarea or KTR All areas in a hospital should always be cleanand healthy to support all the efforts to heal the patients

Restrictions on smoking in hospitals can be an initia-tion to smoking behavior changes especially for hospitalstaff themselves This is important to do considering healthprofessionals are supposed to stay away from smoking andbecome role models for the community in the fight againstthe problems of smoking But in fact many health workers atRSUDZAwere not following the rules and policies to enforcethe application of no smoking in the hospital and its grounds

Health education efforts can teach hospital staff tostop smoking in the hospital and its grounds especiallywith the commitment and support of the Director of theHospital accompanied by supervision and enforcement ofsanctionsThis form of health education can be done throughhealth promotion approaches Health promotion interven-tions (HPI) to change smoking behavior in hospitals caninclude health education including information about thedangers of smoking the chemicals contained in cigarettesand the impact of smoking in general on smokers and othersChanges expected from HPI are an increase in knowledgeimproved attitudes and behavioral changes by personsexposed to the HPI to not smoke especially in public placessuch as hospitals

The concept of health promotion applications varies withthe purpose of the public health behavior change concernedone of them is through the learning process using stimulusand response According to Notoatmodjo [7] the process ofbehavior change in fact is similar to the learning processwhich consists of stimuli which are accepted or rejected andif they are noted understood and accepted by the individualthey result in a change of attitude whence in the end anopen reaction occurs with the change action occurring asexpectedThis concept in principle is relevant to the stimulusinformation which is conveyed about smoking the dangersof smoking and ways of stopping smoking through mediaused in HPI so that gradually an attitude is born and growsto change that is to quit or reduce smoking behavior

Smoking in the Dr Zainoel Abidin Provincial GeneralHospital (RSUDZA) in Banda Aceh and in the hospitalgrounds was still a health problem Numerous attempts hadbeenmade by themanagement of the RSUDZA strengthenedby policies implemented by the Director of the RSUDZAwith oversight conducted by the hospitalrsquos Peoples HealthPromotionUnit (PKMRS)These had also been strengthenedby new regulations with the issue of a city-wide Regulation(Perda) number 6 of 2011 to make all public areas in the Cityof Banda Aceh nonsmoking areas However all these effortshad yet to bear fruit and many visitors and even hospital staffand sometimes even patients could still be found smoking inthe hospital and its grounds

All the data and facts above indicated that the phe-nomenon of smoking in the hospital and its grounds stillremained a health problem and a social problem for avariety of reasons Although smoking had been banned byregulations and supervision was also being carried out thehabit was still there so somemore effectivemethodswere still

needed so that staff and also patients and visitors would nolonger smoke in the hospital and its grounds

One method that can be done is to use HPI approachesto empower hospital staff to adopt healthy behavior withoutreach that is use of media with social support approachesincluding seminars counseling and partnerships with advo-cacy The HPI can build on the commitment of the hospitalDirector as well as the support of regulatory oversight to stopsmoking in the hospital and its grounds HPI approaches areeffective for raising awareness amongst staff to quit smokingeven though only in the hospital and its grounds

Based on the above background this research effort hasbeen directed at finding effective HPI methods that can beapplied to modify the behavior of employees who smoke to(a) stop smoking in the hospital and its grounds and (b) toquit or reduce smoking altogether

12 Problems The phenomenon of smoking by staff of theRSUDZA in Banda Aceh has had implications for the healthfunctions of the organization and for the human resourcefunctions for health because as the premier hospital in Acehit should play an active role and set a leading example in thehealth recovery efforts for all the patients that come to thehospital

Stopping smoking by staff is not an easy goal Waysthat can be used to try to achieve this goal include HPIthat is health education and health promotion approachesempowering staff providing social support and advocacyplus the wholehearted commitment of the Director and theimplementation and enforcement of no smoking regulationsIn summary the research problem formulated is how can theuse of HPI that is health promotion activities empower-ment advocacy and social support influence all the staff ofRSUZA to (a) quit smoking in the hospital and its groundsand (b) quit or reduce smoking altogether

13 Research Question The problems posed above are sum-marized in the following research question can health pro-motion interventions (HPI) including increasing knowledgeabout the dangers of smoking plus building positive attitudesfor behavioral change amongst smokers result in all the med-ical staff of RSUZA (a) quitting smoking in the hospital andits grounds and (b) quitting or reducing smoking altogether

14 Research Objective The purpose of this study was toanalyze the influence of various HPI to get each and everymember of the RSUZA medical staff who smokes to changetheir smoking behavior and henceforth (a) to quit smokingin the hospital and its grounds and (b) to quit or reduce theirindividual smoking habits altogether

15 Hypothesis The hypothesis for this study is ldquoThere areHealth Promotion Interventions (HPI) that can influence thebehavior of employees at RSUZA to (a) quit smoking in thehospital and itrsquos grounds and (b) to quit or reduce the smokinghabit altogetherrdquo


16 Benefits of This Research The benefits of this researchare that it can be an input or reference that is useful forimproving the effectiveness of HPI in order to get all the staffand workers at RSUZA (a) to stop smoking in the hospitaland its grounds and (b) to quit or reduce their smokinghabit altogether It is also expected that this research cancontribute to improvements in the effectiveness of HPI tostop andor to reduce the smoking habit throughout AcehProvince especially in other hospitals health centers andpublic facilities

2 Research Methods

21 Type of Research This research is action research thataims to find and analyze the influence of various HPI inparticular employee empowerment and also social supportand advocacy to change the behavior of hospital staff (a) toquit smoking in the RSUZAHospital and its grounds and (b)to quit or reduce smoking altogether This type of researchcan analyze and reveal facts and phenomena that arise inthe ongoing research Interventions in the research may bechanged in accordance with conditions and situations foundin the field Action research is an integrated approach that isboth quantitative and qualitative

22 Population andResearch Samples Thepopulation for thisstudy whowere exposed to theHPI were all 862medical staffof Dr Zainoel Abidin Provincial General Hospital RSUZAin Banda AcehThe sample selected was all medical staff whoadmitted that they smoked 152 individuals in all

The control group population were from themedical staffat a different hospital in BandaAcehwhere there were noHPIinterventions namely RS Meuraxa which is some distancefrom RSUZA (about 7 km to the south) The control groupalso had a total of 152 medical staff who were self-admittedsmokers

23 Antismoking Interventions Over 50 posters includingsome very graphic ones (refer Appendix) were placed atstrategic locations throughout the hospital Antismokingsigns were put up throughout the hospital and were alsoerected in the grounds Counseling of smokers was given for45minutes a day between 8 and 9 am every working day (ieMonday to Friday) counselingwas conducted by theDirectorhimself and by specialist doctors and others in particularby persons who had suffered major illnesses as a result ofsmoking Details of the interventions and illustrations of theposters and signs are in the Appendix

24 Data Analysis Data analysis in this research includedanalysis of bivariate tests using Chi-square and Fisherrsquos exacttest independent 119905-test and nonparametric Mann-Whitneytests Independent 119905-test was conducted at 95 confidencelevel and the Wilcoxon rank test was conducted at 95confidence level Multivariate analysis used multiple logisticregression tests

Table 1 Knowledge and attitudes of the staff before and after thetests

StageKnowledge Attitude

Good Poor Positive Negative119899 119873 119899 119899

Pretest 87 57 65 42 86 57 66 42Posttest 109 71 43 28 116 76 36 23

Table 2 Description of smoking behavior of smoking medical staff

Smoking behavior (119899) ()Pretest

1 Light smokers (1ndash5 cigarettesday) 77 512 Moderate smokers (6ndash15 cigarettesday) 37 243 Heavy smokers (gt15 cigarettesday) 38 25

Total 152 100Posttest

1 Light smokers 83 542 Moderate smokers 17 113 Heavy smokers 14 94 No longer a smoker 38 25

Total 152 100

3 Results and Discussion

31 Knowledge and Attitudes of Staff before and after the TestsThe results of this research showed that the proportion ofrespondents with good knowledge and attitudes before thepretest were 57 Then after the interventions (posttest)there was an increase in respondentsrsquo knowledge to 71 thatis an increase of 14 and also an increase in those withpositive attitudes to 76 that is an increase of 19 (referTable 1)

32 Change in Smoking Behavior in the RSUZA Hospital andIts Grounds As a result of the HPI interventions includingmore rigorous policing against smokers smoking has beentotally stopped within the hospital and its grounds by all staffand workers plus also by all patients and visitors

33 Changes in Smoking Behavior of Smoking Staff (SmokingAway from the Hospital and Its Grounds) Table 2 shows thatthe highest proportion of respondents in the pretest was thelight smokers with 51 After the interventions (posttest) theproportion of respondents that were light smokers increasedto 54 whilst moderate smokers more than halved with adecrease from 24 to 11 and nearly two-thirds of heavysmokers reduced their smoking significantly with a decreasefrom 25 to 9 and most significantly 38 or 25 of respon-dents quit smoking that is stopped smoking altogetherThusbetween 44 (29) and 82 (54) of the intervention groupcompletely stopped or reduced their smoking with up to 44(29) reducing their smoking and becoming light smokersonly (the number of light smokers increased from 77 to 83)(refer Table 2)


Table 3 Differences in knowledge positive attitudes and smokingbehavior of staff before and after the interventions

Variable Meanpretest

Meanposttest

Meandifference 119885 119875

Knowledge 30 33 3 minus8719 0001lowast

Attitude 83 89 6 minus7644 0001lowast

Quit smoking 8 3 minus5 minus4219 0001lowastlowastSignificant 120572 le 005

Table 4 Multiple log regressionmodels of interventions against thebehavior of quitting smoking

Variable 119861 B (Exp) 119875

Constant minus9103Knowledge 1641 5162 0001lowast

Attitude 1682 5375 0004lowast

Health Promotion Interventions 2481 11949 0001lowastlowastSignificant 120572 le 005

34 Differences in Knowledge Positive Attitudes and SmokingBehavior of Staff before and after the Interventions Table 3shows that there are differences in the intervention groupmeans of 303 Statistical analysis of the results using 119905-testshowed that there was a significant increase in knowledgebetween the pre- and the posttests with a probability valueof 0001 (119875 lt 005)

Based on attitudes there was a mean increase in thepositive attitude of the respondents of 6 Dependent 119905-testresults show that there was a significant increase in staff witha positive attitude before and after the test with a differenceof minus7644 and a score of 119875 = 0001

35 Differences in Knowledge Positive Attitudes and Behaviorof Staff to Quit Smoking before and after HPI The results ofthe multivariate analyses used a log regression test The finalmultiple regression log model results are set out in Table 4

Table 4 shows there are two variables that predict changesin the smoking behavior of staff at RSUZA as a result of healthpromotion interventions (119875 = 0001 OR = 11949)These twovariables are knowledge (119875 = 0001 OR = 5162) and attitude(119875 = 0004 OR = 5375)

This indicates that the intervention campaign conductedwith guidance lectures discussions leaflets and brochureseffectively increased such knowledge amongst the interven-tion group that is the staff who smoked from RSUZA Thecontrol group who were from a different hospital in BandaAceh RS Meuraxa also increased their average score butonly by 005 that is the score was stable thus statisticallythere was no difference in knowledge from the start to theend of the program amongst the control group where therewas no intervention campaign

The formula used for calculating the multiple log regres-sions is as follows

Logit (119884) = 119886 + 11988711198831

Logit (quit smoking behavior) = 119886 + 11988711198831+ 11988721198832

1198831= Health Promotion Intervention

1198832= Attitude

(1)

Thus the calculations are as follows

119884 = 119886 + 23171198831+ 1528

119884 = minus6214 + 2317 (Health Promotion Intervention)

+ 1528 (Attitude)

1198751(119909) =

1

1 + 1198901(minus6214+2317+1528lowast1)=1

1 + 1198901(minus2369)

1198751(119909) = 0916 997888rarr 916

(2)

The proportion of those smokers amongst RSUZA staffwho reduced their smoking behavior as a result of the healthpromotion intervention plus information (about the dangersof smoking) and who had a positive attitude was 916

The most important variables that influenced the quit-ting smoking behavior change were the health promotionintervention and the employeersquos attitude variables thus thestaff who were exposed to the health promotion interventionwere 11949 times more likely to reduce smoking behaviorthan staff who were not exposed to it Similarly staff with apositive attitude to quit smoking were 5375 times more likelyto reduce smoking behavior than staff with a negative attitudeto it

36 The Influence of Increasing Knowledge (about the Dangersof Smoking) fromHPI Interventions amongst StaffWho SmokeResults of the independent 119905-test indicated that there wasa significant difference in knowledge (about the dangersof smoking) between the pretest and the posttest Thisindicates that the intervention campaign conducted withguidance lectures discussions leaflets and brochures effec-tively increased such knowledge amongst the interventiongroup who were staff from RSUZA The control group whowere from a different hospital in Banda Aceh RS Meuraxaalso increased their average score but only by 005 that is thescore was stable thus statistically there was no difference inknowledge before and after the testsinterventions (amongstthe control group)

Increases in knowledge amongst the staff in the inter-vention group are understandable because the informationcontained in such health promotion interventions could beeasily internalized by staff The information was also easilymade available to the employees during their routines atthe hospital through banners leaflets and posters that werestrategically placed throughout the hospital Moreover as themajority of the hospital employees have had higher education(mostly in health) with high-level diplomas degrees andpostgraduate qualifications they can very easily absorb infor-mation about health Increases in knowledge about the harmfrom smoking and the motivations to quit smoking variedconsiderably amongst the employees in the interventiongroup Although employees in hospitals work in a healthprofession this does not guarantee they will not smoke


Knowledge of the dangers of smoking does not guarantee thatdoctors dentists and other health care personnel will avoidthis risky behavior

Effective media can support the delivery of the messagefrom the facilitator because suitable media can stimulate thethoughts feelings concerns objectives and interests of thetarget group during the learning process

37 The Influence of HPI to Increase Employeesrsquo PositiveAttitudes to Stop Smoking The attitudes in this research arethe awareness and willingness of employees of RSUZA tolearn about the dangers of smoking and their willingnessto avoid the dangers of smoking and to adopt antismokingattitudes There are three phases of awareness the firstphase awareness of the dangers of smoking the secondphase avoiding the dangers of smoking and the third phaseadopting antismoking attitudes Attitudes towards health canbe defined as a form of reaction to feelings that can besupported or not provoking thought and a tendency to adoptbehavior that tends towards good health free from pain orillness not only physically but also mentally

The results showed that 57 of the staff had a posi-tive attitude towards nonsmoking before the pretests thisincreased to 76 after the interventions meaning that therewas an increase of 19 in the positive attitude to non-smoking Awareness of the dangers of smoking showed littleincrease from 57 strongly agreeing in the pretest to 59in the posttests after the interventions However most of therespondents verymuch agreed when asked about the dangersof smoking to family health Consciousness of the need to notsmoke in nonsmoking areas increased from42 in the pretestto 53 after the interventionsWhilst 35 of the sample had apositive attitude towards thewill to quit smoking by removingthe sense of dependence on cigarettes 53 had a positiveattitude towards antismoking programs and friends that areantismoking

These results showed that the (hospital) staff tendedto have a positive attitude towards quitting smoking Thisshowed that the staff of the hospital already have awarenessof the desirability to quit smoking This can be understoodbecause generally they have a background education inhealth however factually some also had the habit of smokingThat means that the formation of consciousness or a positiveattitude towards antismoking or interventions to quit smok-ing had not yet sparked real actions to quit smoking or at leastto reduce smoking

Independent 119905-test results showed there were significantdifferences in attitudes before the interventions (pretest)comparedwith the attitudes after the interventions (posttest)This is indicated by the value of the probability of less than0005 with a 95 level of certainty and a value of 119905 = minus7974meaning the difference in attitudes before and after theintervention was 972

In line with the effectiveness of health promotion knowl-edge the attitudes of the staff also changed after the healthpromotion interventions were conducted in the hospitaland its grounds This was a real change resulting from theinternalization of information by the staff about the dangers

of smoking the impact of smoking and changes in behaviorneeded to stop smoking A positive or negative attitudeto things concerned with cigarettes will strongly influencewhether someonersquos smoking behavior tends to be high or not

Interventions to promote health through health promo-tion media will increase knowledge and increase positiveattitudes in staff towards the dangers of smoking Results ofregression tests showed that the staff with positive attitudeswere 53 times more likely to stop smoking compared tothe staff with a negative attitude This fact shows thatinternalization of knowledge which the staff already haveabout smoking will slowly change attitudes and willingnessto begin to stop smoking Health information interventionsconnected to stopping smoking in public places and thedangers of smoking for personal health will form attitudesand willingness to start stopping smoking with reduction inthe number of cigarettes smoked until eventually hopefullysmoking is stopped altogether

38 The Influence of HPI to Get Staff to Stop SmokingStopping smoking is a real-life form of individual behaviorchange to reduce smoking andor not to smoke again Resultsof statistical tests with Mann-Whitney tests show that thesmoking behavior pretest of the intervention group with amean value 838 versus 792 in the control group and averagedifferences of 0769 showed no difference because the valueof the probability was 0699 (119875 gt 005) whilst the smokingbehavior in the posttest had an average difference of 0549which showed significant differences in the smoking behaviorbetween the intervention group and the control group with avalue of 119875 = 0002 (119875 lt 005) which means that with a 95level of confidence the health promotion interventions haveinfluenced changes in the smoking behavior of those exposedto the HPI interventions Independent 119905-test results showedsignificant differences in the smoking behavior before andafter the interventions which is indicated by the value of theprobability being less than 005 (119875 = 0002) at a 95 level ofconfidence with the value of 119905 = minus3040

HPI conducted in phases starting from the stage ofempowerment to counseling conducted en masse and ingroups with messages about the chemicals in cigarettes theeffects of cigarettes and ways to stop smoking were givenby researchers religious leaders and a specialist doctor inpulmonary diseases as well as a former smoking addict whonota bene was also a specialist in radiology This strategyprovided a positive impact to decrease the number of heavysmokers (smokingmore than 15 cigarettes per day) and also toincrease the number of smokerswho decided to stop smokingaltogether This happened because there was informationdirectly from people who had already had serious healthproblems as a result of smoking and had had to undergomajor treatment to regain their health

Besides messages in media such as leaflets flyers andbanners containing antismoking messages (refer Appendix)there were also photographs and messages from publicofficials in particular the Mayor and Deputy Mayor of BandaAceh to show that efforts to combat smoking cigarettes werevery strongly supported by the City of Banda Aceh


The smoking behavior of the hospital medical staff gen-erally started during early adulthood The phenomenon ofstarting the smoking habit in early adulthood has differentcauses than with teenagers According to social stress modelsthe use of addictive substances is one way for persons toovercome various stresses which they are experiencingThesestresses can arise from family (problems) or work (problems)or even from a poor environment One response arisingfrom such stress is the appearance of negative emotions inparticular sadness anger and distress

Such circumstances create environmental factors withthe potential to influence the smoking behavior of peopleBasically hospital staff understand that smoking can causeimpairment of health can affect the local environmentand can impact others as the hospital staff in general havehealth education background thus 79 of the staff in theintervention group already had an intention to stop smokingand 69 of the control group also intended to stop smokingOne of the reasons why they wanted to stop smoking was thatsmoking at homewas not accepted by their families plus therewere pressures at work to stop smoking However some staffwhowere depressed still wanted to smoke to calm themselves

Although a lot of hospital staff already wanted to quitsmoking many still smoked Some said ldquoit is very difficultto quit smokingrdquo because it is an addiction and they relapsedand returned to smoking if they had any stress or problemsAn intention to change is a positive precedent for behaviorchange According to various experts people behave basedon ways that make sense considering the impact of suchbehavior An action to stop smoking needs a strong intentionAny attempt to stop smoking is not easy because we have tochange previous habitual behaviors into new habits

In accordance with the concept of behavior changeexpressed by Rogers and Shoemaker [10] in the theory ofthe Innovation decision process behavior change is defined asthe psychological process experienced by an individual afterreceiving information or knowledge about a new conceptuntil such time as he accepts that new concept If theacceptance of a new behavior through the adoption process isbased on knowledge awareness and a positive attitude thenthe behavior is likely to be long-lasting On the contrary ifbehavior change is not based on knowledge and awareness itwill not last long

Changes in the behavior of hospital staff to quit smokingcan be done in various ways for example by HPI andor byspecial therapy as well as with stimulant health educationnamely stimulation is given to reduce internalization that isthinking about smoking also hypnotherapy can be used

One strategic way to change (smoking) behavior isthrough health promotion interventions (HPI)This researchhas proven that HPI can change the behavior of people toreduce the number of cigarettes smoked per day for exampleheavy smokers can become medium or light smokers or caneven quit smoking altogether

The formation of awareness for smokers who want to quitis a must if they really want to stop Then after smokersreally have awareness to stop smoking with actions orconcrete activities they need to get a touch of the dimensionof affection This is to reinforce the willingness to quit

so the person and the event are really well connected and sothat therewill be a deepmemory trace and thismemory tracewill in turn give reinforcement to not start again

If the intention to quit smoking is strong or high then thesmoking behavior will be weak Nevertheless the intention toquit smoking will still be affected by several factors namelyattitudes towards smoking social support and the abilitywhich the smoker feels to be able to stop smoking Whenhis attitude towards smoking is negative (he feels unhappy tosmoke andor he wants to stop smoking) and social support(from his environment) to quit smoking is also high andthe individual concerned feels highly able to effectively stopsmoking the intention and ability to stop smoking are alsostronger and vice versa

To implement a successful smoking prevention strategyit can be concluded that strategic efforts must be made bythe management of the organization These include tightsupervision to totally stop smoking in the hospital and itsgrounds implementing appropriate sanctions (for transgres-sors) banning the sale of cigarettes in the hospital and itsgrounds plus also increasing health promotions and doingreevaluations every three months Also it may be advisable torenew the HPI from time to time

Three of the 152 individuals in the control group who didnot receive the interventions also quit smoking The reasonfor one person stopping smoking was that he became theDirector of the hospital so he felt ashamed to smoke in thehospital and the reason for the others to stop was that theywere in severe pain which doctors diagnosed to be due tosmoking so they also quit smoking

The commitment of the Mayor of the City of BandaAceh to ban smoking in public places also helped TheMayor and Council have made bylaws and socialized themto make public places nonsmoking areas As reported by theSerambi Daily newspaper on 31st May 2013 the Governmentof Banda Aceh have made stickers for socializing smokingbans in public transport that is minibuses or ldquolabi-labirdquo sothat people are exhorted to change behavior and becomeldquoashamedrdquo to smoke in public In general the nonsmokingareas where smoking is banned are public places includinghealth facilities schools and placeswhere people are teachingand learning plus childrenrsquos playing areas places of worshipworkplaces sports facilities public transport and indoorpublic areas People have not yet responded 100 to thebylaw so sometimes people can still be seen smoking inpublic places Quitting smoking is possible and is an absolutemust even though smoking has become almost inseparablefrom the everyday life of many people

39 Reasons to Stop Smoking Interventions conducted bythe researchers with the health promotion approach resultedin positive impacts and positive behavior changes with allstaff stopping all smoking in the hospital and its groundsQualitatively the reasons to stop smoking included infor-mation from the experience of key note speakers for theHPI activities plus visual information in a video about thedangers of smoking in the short medium and long termbased on personal experiences including the high cost to


clean all the blood vessels in a patientrsquos body from nicotine(a dangerous substance in cigarettes) The format of themessages was the real evidence of damage to parts of the bodydue to nicotine and other harmful substances in cigarettesThis was demonstrated step by step in a video Practicallythese visuals provided real stimulus for change and forthe intention to quit smoking This shows that appropriateintervention materials presented to targets by appropriatemedia and mechanisms can give a positive impact to changethe attitudes and behavior of persons to make them want toquit smoking

One speaker suggested that those persons who havealready had experience in stopping smoking can contributetheir thoughts to other staff to enable them to quit smokingIndeed one reason for RSUZA staff to quit smoking is thecommitment of the leadership of the hospital both to supportthe promotion of the program to quit smoking in the hospitaland to provide support for advocacy and meetings and theDirector himself even took a lead in the advocacy sessionsThis resulted in smokers at RSUZA quitting out of a senseof honor and respect for the hospital leader who was socommitted to get all of his employees not to smoke

This commitmentwas also supported by tight supervisionagainst smoking in the hospital and its grounds that is byempowering security officers to reprimand smokers caughtsmoking in the hospital grounds Indeed this commitmentwas the highest choice selected by the participants thatwanted to stop smoking and was supported by the commit-ment of the Director who instructed that the hospital and allits grounds must be free from cigarette smoke

Quinn and Snyder [11] argue that people need to beempowered to realize deep change or transformation Theycall their program ACT or Advanced Change Theory Thuschanges made by the Director to consistently ensure super-vision and enforcement to stop all smoking in the hospitaland its grounds were able to transform the hospital and itsgrounds into a no smoking oasis Leading by example andcampaigning to stop smoking is one role of the hospital asa health unit to serve the community

Results that have been achieved recently include thepassing of the No Smoking Areas (NSA) Law (Qanun KTR)plus socialization of the resultant ban on smoking in publicplaces and also celebration of Tobacco Free Day Socializingthe ban was done to all walks of life through leaflets postersand banners distributed throughout all Government officesand private as well as public transportation (minibuses andbuses) both intraprovincially to all districts and cities in Acehand interprovincially to provinces outside Aceh besides thehospital made a commitment to monitor the implementationof the NSA Law (KTR Qanun)

The fact that the hospital Director was so concernedand committed to stop smoking in the hospital and itsgrounds was an important factor to motivate some staff tostop smoking in the hospital and its grounds The Directoris the highest authority in the hierarchy of the hospital hehas full power tomake decisions concerning human resourcemanagement in the hospital Staff are reluctant to go againsthis directions and are expected to support what is requestedby their leader including not to smoke in the hospital and its

grounds even though such (conforming) behavior may onlybe shown in front of the leader or only in the hospital and itsgroundsThe hospital is a social environment that has variouscharacteristics including hierarchical interactions Accordingto Giddens [12] social life is more than just individual actionsbut social life is also not just determined by social forcesmeaning that the overall actions and activities performed inthe hospital tend to also have social power considering thatall actions of the hospital staff have a social interaction tooThemessage from the hospital policy initiated by theDirectornot to smoke in the hospital and its grounds is informationreceived by all its staff so that there is a positive interactionto mutually stop all smoking in the hospital and its groundswhether by staff patients or visitors In addition theDirectorin the context of the hospital structure is a free agent (who canset an example) as well as being the top figure in the structureso that he has a dual role which provides social strength tomake a successful program to stop smoking in the hospitaland its grounds

In addition another reason to stop smoking is thepsychological burden each member of staff has as a healthworker meaning that there is awareness of the importance ofeventually quitting all smoking in particular due to the HPIinterventions of this action research program

4 Conclusions and Suggestions

The HPI interventions implemented significantly influencedan increase in knowledge about the dangers of smokingamongst the staff and influenced positive attitudes to stop allsmoking in RSUZA Banda Aceh with the following results

(1) Smoking within the hospital and its grounds has beencompletely stopped including smoking by all staffpatients and visitors

(2) The number of smokers in the medical staff interven-tion group smoking away from the hospital decreasedfrom 100 to 75 (ie a decrease of 25)

(3) As above the number of heavy smokers (gt15 ciga-rettesday) decreased from 25 to 9 in the interven-tion group

(4) Also the number of moderate smokers (6ndash15 ciga-rettesday) in the intervention group decreased from24 to 12

(5) But the number of light smokers (1ndash5 cigarettesday)in the intervention group showed a small increasefrom 50 to 54

Logistic regression tests on the results showed that thevariable that most affected the behavior changes to quitsmoking is the HPI (health promotion intervention) with avalue OR 11949 This means that staff provided with healthpromotion interventions were 11949 timesmore likely to quitsmoking compared to staff who were not given HPI

HPI conducted through mass group and individualcounseling improved employee knowledge about the dangersof smoking so they assisted change in behavior of theRSUDZA medical staff and assisted some of them to quitsmoking


Table 5 Health promotion interventions strategies to change behavior of smoking staff

Approach Purpose Intervention Frequency

EmpowermentProvide andor increase knowledgeawareness and attitudes amongst stafftowards the dangers of smoking

(i) Information campaign to staffconducted en masse and in groups

(i) 45 minutes twice weekly for 4 months

(ii) Distributing printed leaflets(ii) 5 types of media viz Posters LeafletsHandouts Stickers Banners

(iii) Putting up posters in thehospital and its grounds

(iii) For 4 months some eg bannerschanged often

(iv) Putting up no smoking signs (iv) Permanent signs

Social supportProvide technical support forimplementing the decisions to bansmoking in the hospital and its grounds

(i) Socialization(ii) Consultations(iii) Workshop

(iv) Once every 4 months(ii) Every month for 4 months

(iii) Once every 4 months

Advocacy

Provide support direction andwrittenprinted decisions concerning thebanning of smoking in RSUZA hospitaland its grounds

(i) Audiences(ii) Consultations(iii) Meetings(iv) Reports

(i) 6 times every 4 months (ie aboutevery 3 weeks)(ii) 6 times every 4 months(iii) 6 times every 4 months

(iv) Every month for 4 months

Empowerment of staff

Social support

Health promotion interventions [HPI](1) Mass indoctrination(2) Group indoctrination (3) Socialization

(a) Leaflets and brochures(b) Posters(c) Signs banning smoking(d) Banners banning smoking

Advocacy

Increase in knowledge andpositive attitude of staff

Reduction in smoking ortotally quitting smoking

(1) Seminars(2) Workshops(3) Consultations(4) Working together with foreign LSM and NGOs(5) Senior staff at hospital

(1) Commitment and support of stakeholders(2) Laws banning smoking(3) No smoking areasprecincts(4) Support from governor and city mayor

Schematically the strategy to increase knowledge change attitudes and change smokingbehavior of the RSUZA medical staff is as shown in the figure below

Figure 1 Model for change in smoking behavior of staff at RSUZA Hospital Strategy for increasing knowledge improving attitudes andchanging smoking behavior amongst the staff at the RSUZA Hospital

Putting up posters about the dangers of smoking in thehospital and its grounds and installation of signs banningsmoking at strategic locations throughout the hospital createda positive attitude amongst staff and a conducive environmentfor all staff workers patients and visitors to not smoke in theRSUZA Hospital and its grounds Strategic empowerment

social support and advocacy carried out comprehensivelyand continuously can change behavior to reduce smoking andeven got some staff to stop smoking away from the hospital

It turns out that the commitment of the hospital Directorcan influence medical staff to change their smoking behaviorThese changes can be done by making regulations for no


(a) (b)

Figure 2 (a) Horror wall poster citing effects of smoking (b) Another horror wall poster showing effects of smoking Both posters in bothAcehnese and Indonesian languages

(a) (b)

Figure 3 Examples of antismoking wall signs free-standing signs and wall posters used

smoking in a hospital and its grounds and by close supervi-sion of staff to ensure they do not smoke in the hospital andits grounds

Suggestions

(1) The Government of Aceh Province the City of BandaAceh and other districts in Aceh through the AcehProvincial Health Department and City and DistrictHealth Departments need to

(a) run routine quarterly evaluations of the imple-mentation of the policy of nonsmoking areas inpublic places particularly in hospitals

(b) immediately set out and pass Qanuns or locallaws to implement smoke-free areas through-out the Province of Aceh in order to reducethe number of smokers in public places in

the Province of Aceh particularly in hospitalsand other health facilities

(c) set policies for oversight mechanisms and tech-nical surveillance to ensure no smoking policyin designated No Smoking Areas

(d) program FPI in other public institutions(e) place thousands of posters leaflets and banners

in public places providing information aboutthe dangers of smoking

(2) Dr Zainoel Abidin Provincial General Hospital(RSUDZA) in Banda Aceh needs to

(a) continue to thoroughly implement the KTR(smoke-free area) policy in the hospital and itsgrounds including policy of the no smokingcondition and prohibiting the sale of cigarettes


(a) (b)

Figure 4 (a) Left above example of freestanding ldquoNo Smoking Areardquo sign erected outside Centre example ofNo Smoking wall poster Belowexample of ldquoNo Smoking Areardquo wall sign (b) Above Thank You for Your Attention with no smoking sign used in slide presentations

in the hospital and its grounds so that thehospital areas are completely free from cigarettesmoke

(b) have systematic and structured surveillance aswell as strict sanctions implemented by theDirector of the hospital imposed on all staffworkers patients and visitors who dare to try tosmoke in the hospital or its grounds

(c) sustain and continue the HPI that have beenintroduced in partnerships with other associ-ated institutions to increase the awareness ofstaff and of patients in the hospital as well asvisitors of the hospital to stop smoking

(d) continuously maintain the present policies ofthe Director of RSUZA to be monitored andcommitted to no smoking policy in the hospitaland its grounds in spite of any changes andnew dynamics that may be introduced by futuredirectors of RSUZA

(e) have support for the commitment by the Direc-tor of RSUZA Banda Aceh to continue the pol-icy of banning smoking in the RSUDZA hospi-tal and its grounds in order to allow the hospitalmanagement to continuously maintain the banin the future

Recommendations for Academia

(1) Follow-up studies need to be done with regard toother types of health promotion interventions (HPI)using comparative analysis for different media andother variables in hospital management

(2) There is a need for further study and analysis ofpolicies and methods of intervention to get behaviorchange to stop smoking that can be a reference forimplementation in other hospitals and institutions

Appendix

See Table 5 and Figures 1 2 3 and 4

Definitions

Smoking behavior Smoking of cigarettes cigarsandor pipe tobacco regularly

Quit or stop smoking Stopping smoking behavioraltogether

Reduced smoking Going down from one smokinglevel to a lower one

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper

References

[1] S Shiffman ldquoAssessing smoking patterns and motivesrdquo Journalof Consulting and Clinical Psychology vol 61 no 5 pp 732ndash7421993

[2] A McEwen P Hajek H McRobbie and R West Manual ofSmoking Cessation a Guide for Counselors and PractitionersBlackwell Oxford UK 2007

[3] S Cofta and R Staszewski ldquoHospital staff and smoking habitsdo we need modification of smoking behavior in polish hospi-talsrdquo Journal of Physiology and Pharmacology vol 59 no 6 pp191ndash199 2008

[4] M N Moneer M K Noaman and N A Labib ldquoSmokingbehavior knowledge and attitudes among medical workers inthe National Cancer Institute Cairo Universityrdquo Journal ofAmerican Sceince vol 7 pp 1059ndash1064 2011

[5] A Nagle M Schofield and S Redman ldquoAustralian nursesrsquosmoking behaviour knowledge and attitude towards providingsmoking cessation care to their patientsrdquo Health PromotionInternational vol 14 no 2 pp 133ndash144 1999


[6] R M Kaplan and F S James Health and Humans McGraw-Hill New York NY USA 1992

[7] S Notoatmodjo Promosi Kesehatan PT Rineka Cipta JakartaIndonesia 2006

[8] L Green Promotion Planning and Education An EnvironmentalApproach Institute of Health Promotion Research University ofBritish Colombia British Colombia Canada 1980

[9] C G Helman Culture Health and Illness Butterworth-Heineman Oxford UK 1994

[10] E M Rogers and F F ShoemakerDiffusion of Innovations FreePress New York NY USA 5th edition 2003

[11] R E Quinn and N T Snyder Advanced Change Theory inConger J A et al Leaders Change Handbook Jossey-Bass SanFrancisco Calif USA 1st edition 1999

[12] A Giddens Central Problems in Social Theory Polity PressLondon UK 2nd edition 1993

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US$185 million per year (WHO 2011) which is 12 (twelve)times greater than the cost of the cigarettes themselves

Smoking can cause harm to health because smoke froma tobacco cigarette contains over 7000 chemicals many ofwhich are very dangerous to health including many whichcan cause cancer especially the three main components ofthe smoke namely nicotine tar and carbon monoxide In2012 theWHO stated that smoking is a cause of cancer heartdisease strokes and lung diseases (including bronchitisemphysema and chronic pulmonary obstruction [CPO])

Various studies have proven that smoking is extremelyharmful to health According to McEwen et al [2] theleading causes of death associated with smoking are cancercardiovascular disease and pulmonary diseases like bron-chitis emphysema that is CPOD and pneumonia Researchat Sanglah General Hospital in Denpasar Bali showedthat amongst patients who sought treatment for pulmonarydiseases 71 of the patients who sought treatment for lungdisease had been exposed to cigarette smoke Of these 14were active smokers 42 were former smokers and the rest15 were passive smokers that is people who lived withsmokers

Some health workers in clinics health centers hospitalsand other health related institutions also smoke Researchby Cofta and Staszewski [3] at the Hospital of the LordrsquosTransfiguration in Poland found that 27 of health carepersonnel were smokers 35 of these were nurses what ismore 82 of them smoked at work The research of Moneeret al [4] at the National Cancer Institute Cairo Egyptfound 20 of health workers were active smokers 5 wereoccasional smokers and the rest 75 were nonsmokers

Research by Nagle et al [5] with nurses at six hospitals inNew South Wales Australia found that knowledge amongstnurses about the damage to health caused by smoking signifi-cantly lowered the habit of smoking whilst working and suchknowledge tended to be influenced by information aboutsmoking bans and awareness to change This indicates thatthe continuous delivery of information to hospital employeesboth medical personnel and others can influence the healthbehavior of the employees concerned in particular it canresult in the employees concerned changing that is reducingtheir smoking behavior

The reasons a person smokes vary a lot A person learnsabout smoking from their environment Initially they observepeople smoking After they try smoking for the first timesome individualsmay feel a desire to smoke again for a varietyof reasons for example to reduce anxiety to lose the feelingof overload and stress from work to feel accepted within aparticular group and for some to relax especially because ofstress from family or other problems

When the smoking habit is already formed social fac-tors play an important role to keep the smoking behaviorgoing According to Kaplan and James [6] the tendencyof individuals to continue to smoke is a phase to sustainthe smoking behavior stage that is a stage in behavior dueto a combination of psychological factors and biologicalmechanisms

Smoking behavior is one type of behavior that can bechanged According to Notoatmodjo [7] change in behavior

can be categorized into three types namely (1) naturalchanges mainly due to changes in the physical environmentor to changes in social cultural or economic activities withrespect to the individual (2) planned change that is changein behavior due to planning by the individual concernedand (3) change due to the willingness for change (readinessfor change) that is changes due to innovations and newprograms that allow individuals to change Changes can berapid or slow depending on each individualrsquos willingnessAccording to various experts behavior can be changed if itis based on strong intentions and a belief that such changesin behavior will be good plus there is strong motivation tochange

Behavior change according to Green [8] is influenced bythree main factors namely (1) predisposing factors that isfactors which more easily affect someonersquos behavior amongstother things knowledge beliefs values traditions and soforth (2) enabling factors that is factors that facilitatebehavior or that enable action and they include tools andinfrastructure or facilities for the behaviors to be done and(3) reinforcing factors (amplifier factors) that is factorsthat encourage or strengthen the occurrence of the behaviorconcerned Even if someone knows and is able to adopthealthy behavior they sometimes do not do so for variousreasons

Smoking behavior can be changed however stoppingsmoking behavior is not an easy thing Results from surveysconducted by the LMMM (LembagaMenanggulangiMasalahMerokok or Foundation for Overcoming Smoking Problems)show that 66 of smokers have tried to quit smoking buthave failed Some failed because they did not know howto stop smoking and some failed because they said theyfound it too hard to concentrate when not smoking Ofthe respondents who successfully quit smoking 76 didso because of awareness itself 16 because of illness and8 because of the demands of their profession according toHelman [9]

Changing the behavior of smoking of health workers orstaff at a hospital is not an easy thing to do Efforts to stopthe smoking habits of staff in hospitals can be done with ahealth education approach In general hospital employeesare individuals with a background of health who alreadyunderstand and know about the impact of smoking tobaccoand cigarettes and the effects of the smoke itself on othersnevertheless it is a fact thatmany healthworkers smoke thusit can be assumed that the approach to change the behaviorof hospital employees to get them to quit their smoking habitwill not be easy But one thing that can be done is to stopthe staff who smoke from smoking in the hospital and itsgrounds

This is supported by Public Health Act number 36 of 2009that makes public places in particular public hospitals NoSmoking Areas (KTR or Kawasan Tanpa Rokok) A hospitalis an institution that provides complete health services toindividuals including in-patient out-patient and emergencyservices One function of a hospital is (health) maintenanceand improvement of individual health through completehealth services according to medical needsThat is a hospitalis a place to get treatment that hopefully does not cause other


















2 Research Methods















Total 152 100








Meanposttest
















Logit (119884) = 119886 + 11988711198831



1198832= Attitude

(1)


119884 = 119886 + 23171198831+ 1528


+ 1528 (Attitude)

1198751(119909) =

1

1 + 1198901(minus6214+2317+1528lowast1)=1

1 + 1198901(minus2369)

1198751(119909) = 0916 997888rarr 916

(2)
































































Advocacy






Social support



Advocacy











(a) (b)


(a) (b)



Suggestions











(a) (b)










Appendix


Definitions






References



















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

































2 Research Methods















Total 152 100








Meanposttest
















Logit (119884) = 119886 + 11988711198831



1198832= Attitude

(1)


119884 = 119886 + 23171198831+ 1528


+ 1528 (Attitude)

1198751(119909) =

1

1 + 1198901(minus6214+2317+1528lowast1)=1

1 + 1198901(minus2369)

1198751(119909) = 0916 997888rarr 916

(2)
































































Advocacy






Social support



Advocacy











(a) (b)


(a) (b)



Suggestions











(a) (b)










Appendix


Definitions






References



















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of



















Meanposttest
















Logit (119884) = 119886 + 11988711198831



1198832= Attitude

(1)


119884 = 119886 + 23171198831+ 1528


+ 1528 (Attitude)

1198751(119909) =

1

1 + 1198901(minus6214+2317+1528lowast1)=1

1 + 1198901(minus2369)

1198751(119909) = 0916 997888rarr 916

(2)
































































Advocacy






Social support



Advocacy











(a) (b)


(a) (b)



Suggestions











(a) (b)










Appendix


Definitions






References



















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of











































































Advocacy






Social support



Advocacy











(a) (b)


(a) (b)



Suggestions











(a) (b)










Appendix


Definitions






References



















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















(a) (b)


(a) (b)



Suggestions











(a) (b)










Appendix


Definitions






References



















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















(a) (b)










Appendix


Definitions






References



















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















research article changing smoking behavior of staff at...

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