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Vera Nierkens
Smoking in a multicultural society: developing a culturally sensitive
questionnaire
24 april 2006 Measuring determinants of smoking 2
The Netherlands and its immigrants
• Approximately 10% of non-Western background
• Of the 16 million people living in the Netherlands: – 316,000 from Morocco– 358,850 from Turkey– 329,500 from Surinam
• Turks and Moroccans: economic migrants• Surinamese: former Dutch colony
24 april 2006 Measuring determinants of smoking 3
Percentage of smokers (adults)
0
20
40
60
80
100
T M S NL0
20
40
60
80
100
T M S NL
Men Women
24 april 2006 Measuring determinants of smoking 4
Aim of the study
Why this studyTo little information about smoking behaviour available to develop anti-smoking programs
AimTo collect information about smoking and smoking cessation and its determinants among people aged 35 – 60.
24 april 2006 Measuring determinants of smoking 5
Theoretical model
contextual factors
acculturation
education
beliefs smoking cessation
attitudes (advantages and disadvantages)
social influences
self efficacy
motivation
smo-king beha-viour
6
Trial
Maintenance
Plans
Performance Skills
Behavior State
Precontemplation
Contemplation
Preparation
Motivation Factors
Attitude:Pros & Cons
Rational & Emotional
SocialInfluences:
NormsModellingPressure
Efficacy: RoutineSocial
SituationalStress
Behavioral factors
PredisposingFactors
Psychological factors
Biological factors
Social Cultural factors
InformationFactors
Risk Perception
Knowledge
Cues to Action
Intention State
Barriers
Ability Factors
Message
Source
Channel
AwarenessFactors
The I-CHANGE ModelDe Vries et al., 2004; 2005
24 april 2006 Measuring determinants of smoking 7
Methods
Survey
To gain insight into the beliefs that may motivate smokers to quit among
385 Turks, 316 Moroccans and 1072 Surinamese
Developing questionnaires and pilot testing
24 april 2006 Measuring determinants of smoking 8
Developing a questionnaire
1. Eliciting salient beliefs
2. Development of questionnaires
3. Pilot testing of the questionnaire
24 april 2006 Measuring determinants of smoking 9
1. Eliciting salient beliefs
Focus group interviews• Recruitment of participants
– recruitment by key persons
– location of interviews: familiar to participants
• Ethnic matching
– native language
– feel free to talk: taboo
• Interpretation of qualitative results
• Appropriate theoretical background?
– classifying beliefs 97% classified
24 april 2006 Measuring determinants of smoking 10
Results of the qualitative study
Similar to Dutchsmoking• relaxing effect• makes feel comfortable• increases health risksquitting• makes one proud• eating more • retraction symptoms
Different from Dutch• sign of modernization for
women• offering cigarettes sign of
kindness• different social influences• If smoking is not allowed
women smoke in secret
24 april 2006 Measuring determinants of smoking 11
2. Development questionnaire
• Selection beliefs• Belief formulation: adaptation to preferences • Answer format: adaptation to ‘verbal answer’
– face to face interview!
• Translation– preparatory discussion with forward translator – afterwards: discussion with forward and back
translators– meaning of the translations!
24 april 2006 Measuring determinants of smoking 12
3. Pilot testing
• Interview method – fluency in Dutch– educational level
• Final selection of the questions– differences between smokers and non-smokers– internal consistency– clarity of questions (number of missing values)– content validity– comparability with other groups
24 april 2006 Measuring determinants of smoking 13
Results item selection (examples)
Included • Do you feel comfortable
(if you smoke)• If I smoke, I will be
ashamed• II I quit would be proud • If I quit, better for health• Social influences family
and friends
Excluded • If I smoke, I will not be
accepted • Social influence
colleagues, children, parents
• If I quit I get a better condition
• If I smoke I forget my problems
24 april 2006 Measuring determinants of smoking 14
The result
• Three questionnaires including:– questions, formulation adapted to group– similar beliefs and some ‘culturally specific beliefs’
• Reliable scales for attitudes, social influences and self-efficacy (alpha between 0.66 – 0.95)
• Sufficient explained variance for Turkish and Moroccan men (66%)
24 april 2006 Measuring determinants of smoking 15
Concluding remarks
• Combination of qualitative and quantitative methods
• Adapt methods; use key persons• Ethnic matching• Be open minded• Etic and emic beliefs• Translation: be aware of the meaning