Process evaluation and challenges of implementation of a school-based waterpipe tobacco smoking prevention program for teens in Lebanon
Dima Bteddini 1
Rima Afifi 1
Lina Jbara 1
Hala Alaouie 1
Lama Al Aridi 1
Ziyad Mahfoud 3
Rima Nakkash 1  
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Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
Biostatistics, Epidemiology and Biomathematics Research Core, Weill Cornell Medical College, Doha, Qatar
Department of Global and Public Health, Weill Cornell Medical College, Doha, Qatar
Department of Medicine, Hamad Medical Corporation, Doha, Qatar
Rima Nakkash   

Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
Publish date: 2017-04-21
Submission date: 2016-07-25
Final revision date: 2017-03-30
Acceptance date: 2017-04-01
Tob. Prev. Cessation 2017;3(April):11
Waterpipe tobacco smoking is increasing globally particularly among youth. In Lebanon,the high prevalence of waterpipe tobacco smoking among younger age groups calls for immediate intervention particularly given its negative health effects. To date, such interventions have rarely been implemented or evaluated.

This manuscript describes the process evaluation of a school-based intervention to prevent/ delay waterpipe tobacco smoking among 6th and 7th graders (n=844) in Lebanon. Process evaluation documents whether an intervention is implemented as planned, and guides understanding of the relationship between the intervention activities and outcomes. The intervention was carried out over 5 months during 2011-2012 on school premises and during school hours, using a participatory approach. The ten intervention sessions included knowledge, skills and a social promise. The process evaluation assessed fidelity, dose delivered, dose received, reach, satisfaction, and the influence of context. Tools included observation and satisfaction forms, attendance log sheets, focus group discussions, and daily journal entries.

The majority of participants (87.2%) attended at least 75% of the sessions. Results indicate high fidelity of implementation; 72.3% of the activities were rated by facilitators to be fully implemented - with high participant satisfaction; 89.5% of children chose a happy face to express their rating of the session. Facilitators rated children’s participation as ‘positive and active’ in 77.9% of the sessions.

Main challenges to implementation were contextual at the country and school level, and related to local pro social norms around waterpipe tobacco smoking. The experience of this intervention confirms the critical importance of context in program implementation.

Akl, E.A., et al., The prevalence of waterpipe tobacco smoking among the general and specific populations: a systematic review. BMC Public Health, 2011. 11(1): p. 1-12. doi: 10.1186/1471-2458-11-244.
Maziak, W., et al., The global epidemiology of waterpipe smoking. Tobacco Control, 2015. 24(Suppl 1): p. i3-i12. doi: 10.1136/tobaccocontrol-2014-051903.
Akl, E.A., et al., The effects of waterpipe tobacco smoking on health outcomes: a systematic review. Int J Epidemiol, 2010. 39(3): p. 834-57. doi: 10.1093/ije/dyq002.
El-Zaatari, Z.M., H.A. Chami, and G.S. Zaatari, Health effects associated with waterpipe smoking. Tob Control, 2015. 24 Suppl 1: p. i31-i43. doi: 10.1136/tobaccocontrol-2014-051908.
Raad, D., et al., Effects of water-pipe smoking on lung function: a systematic review and meta-analysis. Chest, 2011. 139(4): p. 764-74. doi: 10.1378/chest.10-0991.
WHO, Global Youth Tobacco Survey, Country Fact Sheets: Lebanon (Ages 13-15). 2012: Geneva, Switzerland.
CAS, Multiple Indicators Cluster Survey, round 3 (MICS3): Final report. 2009, Central Administration of Statistics in collaboration with UNICEF: Lebanon.
Thomas, R.E., J. McLellan, and R. Perera, School-based programmes for preventing smoking. Cochrane Database Syst Rev, 2013. 4: p. Cd001293.
Saraf, D.S., et al., A systematic review of school-based interventions to prevent risk factors associated with noncommunicable diseases. Asia Pac J Public Health, 2012. 24(5): p. 733-52. doi: 10.1177/1010539512445053.
Reddy, K.S., et al., Tobacco and alcohol use outcomes of a school-based intervention in New Delhi. Am J Health Behav, 2002. 26(3): p. 173-81. doi: 10.5993/AJHB.26.3.2.
Gabble, R., et al., Smoking Cessation Interventions for Youth: A Review of the Literature. February 2015, Ontario Tobacco Research Unit: Toronto.
Johnson, C.A., et al., Why smoking prevention programs sometimes fail. Does effectiveness depend on sociocultural context and individual characteristics? Cancer Epidemiol Biomarkers Prev, 2007. 16(6): p. 1043-9. doi: 10.1158/1055-9965.epi-07-0067.
Milton, M., et al., Youth Tobacco Cessation: A Guide for Making Informed Decisions. 2004, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention: Atlanta.
Chaaya, M., et al., Implementation of an indoor smoking ban and an advertising/ sponsorship ban in Lebanon: a baseline cross-sectional study. Tobacco Prevention & Cessation, 2016. 2(May). doi: 10.18332/tpc/63118.
Heydari, G., et al., The second study on WHO MPOWER tobacco control scores in Eastern Mediterranean Countries based on the 2013 report: improvements over two years. Arch Iran Med, 2014. 17(9): p. 621-5. doi: 0141709/aim.007.
Rychetnik, L., et al., Criteria for evaluating evidence on public health interventions. J Epidemiol Community Health, 2002. 56(2): p. 119-27. doi: 10.1136/jech.56.2.119.
WHO, WHO Framework Convention on Tobacco Control. 2003: Geneva, Switzerland: World Health Organization.
Baranowski, T. and G. Stables, Process Evaluations of the 5-a-Day Projects. Health Education & Behavior, 2000. 27(2): p. 157-166. doi: 10.1177/109019810002700202.
Saunders, R.P., M.H. Evans, and P. Joshi, Developing a process-evaluation plan for assessing health promotion program implementation: a how-to guide. Health Promot Pract, 2005. 6(2): p. 134-47. doi: 10.1177/1524839904273387.
Basch, C.E., et al., Avoiding type III errors in health education program evaluations: a case study. Health Educ Q, 1985. 12(4): p. 315-31. doi: 10.1177/109019818501200311.
Oakley, A., et al., Process evaluation in randomised controlled trials of complex interventions. Bmj, 2006. 332(7538): p. 413-6. doi: 10.1136/bmj.332.7538.413.
Helitzer, D.L. and S.J. Yoon, Process evaluation of the Adolescent Social Action Program in New Mexico, in Process Evaluation for Public Health Interventions and Research, A. Steckler and L. Linnan, Editors. 2002, Jossey-Bass: San Francisco, CA. p. 83-109.
Linnan, L. and A. Steckler, Process evaluation for public health interventions and research: an overview, in Process Evaluation for Public Health Interventions and Research, A. Steckler and L. Linnan, Editors. 2002, Jossey-Bass: San Francisco, CA. p. 2-24.
Moore, G.F., et al., Process evaluation of complex interventions: Medical Research Council guidance. BMJ : British Medical Journal, 2015. 350. doi: 10.1136/bmj.h1258.
Nakkash, R.T., et al., Process evaluation of a community-based mental health promotion. doi: 10.1093/her/cyr062.
McLeroy, K.R., et al., An ecological perspective on health promotion programs. Health Educ Q, 1988. 15(4): p. 351-77. doi: 10.1177/109019818801500401.
Ottersen, O.P., et al., The political origins of health inequity: prospects for change. The Lancet, 2014. 383(9917): p. 630-667. doi: 10.1016/S0140-6736(13)62407-1.
CSDH, Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. 2008: Geneva: World Health Organization.
Black, N., Why we need observational studies to evaluate the effectiveness of health care. BMJ : British Medical Journal, 1996. 312(7040): p. 1215-1218. doi: 10.1136/bmj.312.7040.1215.
Victora, C.G., J.-P. Habicht, and J. Bryce, Evidence-Based Public Health: Moving Beyond Randomized Trials. American Journal of Public Health, 2004. 94(3): p. 400-405. PMC: 1448265
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Rima Nakkash, Tamara Lotfi, Dima Bteddini, Pascale Haddad, Hala Najm, Lina Jbara, Hala Alaouie, Lama Al Aridi, Ahmad Al Mulla, Ziyad Mahfoud, Rima Afifi
International Journal of Environmental Research and Public Health