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EFFECTIVENESS OF PLANNED TEACHING PROGRAMME ON THE ILL-EFFECTS OF TOBACCO USE AMONG ADOLESCENTS IN A SELECTED HIGH SCHOOL, MANGALORE

by RENU SHUKLA

Dissertation submitted to Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka In partial fulfilment of the requirements for the degree of

Master of Science in Nursing


(Psychiatric Nursing)
Under the guidance of

Prof. (Mrs.) Mallika Asith


Department of Psychiatric Nursing

Dr. M. V. Shetty Institute of Health Sciences Mangalor e 2008

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Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation/thesis titled Effectiveness of planned teaching programme on the ill-effects of tobacco use among adolescents in a selected high school, Mangalore is a bonafide and genuine research work carried out by me under the guidance of Mrs. Mallika Asith, Dr. M. V. Shetty Institute of Health Sciences, Mangalore.

Date : Place : Mangalore Renu Shukla

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CERTIFICATE BY THE GUIDE

This is to certify that the dissertation titled Effectiveness of planned teaching programme on the ill-effects of tobacco use among adolescents in a selected high school, Mangalore is a bonafide research work done by Renu Shukla in partial fulfilment of the requirement for the degree of Master of Science in Nursing (Psychiatric Nursing).

Mrs. Mallika Asith, M. Sc. (N) Date: Place: Mangalore Head of the Department Psychiatric Nursing Dr. M. V. Shetty Institute of Health Sciences

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ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF THE INSTITUTION

This is to certify that the dissertation titled Effectiveness of planned teaching programme on the ill-effects of tobacco use among adolescents in a selected high school, Mangalore is a bonafide research work by Renu Shukla under the guidance of Mrs. Mallika Asith, HOD, Department of Psychiatric Nursing.

Seal & Signature of HOD Mrs. Mallika Asith

Seal & Signature of the Principal Prof. (Mrs.) B. V. Kathyayani

Date: Place: Mangalore

Date: Place: Mangalore

COPYRIGHT

Declaration by the candidate

I hereby declare that the Rajiv Gandhi University of Health Science, Karnataka shall have the rights to preserve, use and disseminate this dissertation/thesis in print or electronic format for academic/research purpose.

Date : Place : Mangalore

Renu shukla

Rajiv Gandhi University of Health Sciences, Karnataka

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ACKNOWLEDGEMENT

I praise and thank Almighty for his abundant blessings showered during the course of the study. I owe a deep sense of gratitude to those who have contributed to the successful completion of this endeavour. I am immensely thankful to Dr. M. Ramgopal Shetty, the secretary of Dr. M. V Shetty memorial trust for giving me an opportunity to undertake the post graduation course in this esteemed institution. One looks back with appreciation to the brilliant teachers, but with gratitude to those who touched our human feelings My heartfelt thanks to my guide Mrs. Mallika Asith, Associate Professor, Dr. M. V. Shetty Institute Of Health Sciences, for her expert guidance, vigilant supervision, personal interest and patience in helping me to complete this study successfully. I am greatly indebted to her for making my research experience rich and rewarding. My heartfelt thanks to Prof. (Mrs.) B. V. Kathyayani, Principal, Dr. M. V. Shetty Institute of Health Sciences, for her encouragement, inspiration, support as well as for providing all facilities for successful completion of this study. I owe my sincere thanks with gratitude and respect to my co-guide Mrs. K.Shanthakumari, Vice Principal, Dr. M. V. Shetty Institute of Health Sciences, for her valuable guidance and ongoing encouragement. An understanding heart is everything in a teacher... My sincere and special word of thanks to Ms. Rajesh. and Ms. Madhumitha, Lecturers, Dr. M. V. Shetty

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Institute of Health Sciences, for their ongoing support and encouragement throughout my study. I extend my sincere thanks to Mrs. Shilpakala K., Lecturer in Statistics, Dr. M. V. Shetty Institute of Health Sciences, and to Mrs. Sucharita for her help and guidance in all the statistical analysis involved in the study. I am grateful to Ms. Remya V.S., Lecturer, Dr. M. V. Shetty Institute of Health Sciences, Ms. Savitha Vas, Assistant Lecturer in Nursing for the valuable suggestions and timely help. Acknowledgement is extended to the principals of the schools for permitting me to conduct the study in their schools and my deepest thanks to the participants for extending their cooperation without which it would have been impossible for me to get relevant data for my study. I extend my heartfelt gratitude to all the experts who have contributed with their valuable suggestions in validating the tool and planned teaching programme. A word of appreciation to all the staff of the library, IHS for their sincere help and whole hearted cooperation. Words are not enough to express gratitude to my beloved husband

Dr R.K. Tripathi and my daughter Palak for their constant support, interest, encouragement, sacrifice as well as prayers. The blessings of the almighty are innumerable I have been blessed with supportive family consisting of my in-laws, mother, brother, sister and nephews who are the essence of my existence.

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My sincere thanks to all my classmates and friends specially Sharad, Sofia, Shuba and Pathima Voilet for making me successful in all the encounters and difficulties faced during the study. A word of appreciation to Mr. Roshan and his assistant for their timely help and co-operation in working of this thesis to its present order. Last but not the least my gratefulness is extended to all those who have directly or indirectly helped me in the completion of this study.

Renu shukla

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LIST OF ABBREVIATIONS USED

PTP : N: SD : VHS : WHO :

Planned teaching programme Sample size Standard deviation Very highly significant World Health Organisation

ABSTRACT
A study to determine the effectiveness of planned teaching programme on ill effects of tobacco use among adolescents in a selected high school, was carried out by Renu shukla in partial fulfilment for the award of Master of nursing at Dr MV Shetty Institute of health sciences, Mangalore. The objectives of the study were to : 1. identify the pre-existing knowledge of adolescents regarding the ill-effects of tobacco using a structured questionnaire. 2. design and administer a planned teaching programme on the ill-effects of tobacco. 3. find the effectiveness of teaching programme using the same structured questionnaire. The conceptual framework was based on Penders Health Believe Model. The study attempted to examine the following hypothesis. H1: The mean post-test knowledge scores of adolescents regarding ill-effects of tobacco use will be significantly higher than their mean pre-test knowledge scores. Independent variable was an intervention in terms of planned teaching programme (PTP) on ill effects of tobacco use among adolescents between the age group of 12-16years. Dependent variable was change in knowledge on ill-effects of tobacco use as measured by a structured knowledge questionnaire. Extraneous

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variable were the students age, place of living, family history of tobacco use and exposure to mass media. The research approach used was evaluative approach with one group pre test , post test pre experimental design. The study was conducted in a selected high school at Mangalore. The researcher used a simple random sampling technique for the selecting the location of data collection and selecting the required number of samples. The data was obtained by using demographic Performa and structured knowledge questionnaire on ill effects of tobacco use. The content validity of the developed tool was established by nine experts and necessary modification were made as suggested by them. Reliability of knowledge questionnaire was made by split half method, spearmen brown prophecy formula. Obtained reliability coefficient was 0.82. The investigator also developed the planned teaching programme on ill effects of tobacco use and benefits and the steps of giving up tobacco. A criteria checklist was developed and nine experts validated the content against the criteria check list. Pilot study was conducted among five students who fulfilled the sampling criteria in government high school, Kavoor, Mangalore. Data collection for the main study was conducted in Pompoi High School at Mangalore from 31 September. Results Findings revealed that the mean post-test score was significantly higher than their mean pre-test score. The calculatedt value (t=27.649 p<0.005) was greater than the table value at 0.005 in all sections. The PTP was found to be an effective teaching
st

august to 10

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strategy in increasing the knowledge of the school children regarding ill effects of tobacco use. Keywords: Ill-effects of tobacco use, Planned teaching programme, adolescents, knowledge score, effectiveness.

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TABLE OF CONTENTS

Chapter No. Title Page No.

1.

Introduction 1

2.

Objectives

13

3.

Review of literature

14

4.

Methodology

28

5.

Results

43

6.

Discussion

68

7.

Conclusion

75

8.

Summary

76

9.

Bibliography

84

10.

Annexures

92

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LIST OF TABLES
Table No. Title No 1. Assessment of knowledge of the students regarding ill55 effects of tobacco use 2. Description of area wise Mean, SD, Mean Percentage of knowledge score 3. Distribution of percentage of correct responses of students on ill-effects of tobacco use 4. Area wise effectiveness of PTP with mean SD and mean percentage of Pre-test and Post-test knowledge scores of students 5. Effectiveness of PTP based on items-wise correct responses of the students in pre-test and post-test with regard to ill-effect of tobacco use 6. Significance of difference between pre-test and post-test 67 knowledge scores 64 62 57 56 Page

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LIST OF FIGURES
Figure Page

No. Title No 1. Modified Conceptual Frame Work based on Penders Health 12 Promotion Model (1996) 2. 3. 4. 5. Schematic representation of the Research Methodology Schematic representation of sampling procedure Percentage distribution of students according to the gender Percentage distribution of students according to the type of family 6. 7. Percentage distribution of students according to religion Percentage distribution of students according to the occupation of their parents 8. Percentage distribution of students according to the monthly income of family 9. 10. Percentage distribution of parents according to marital status Percentage distribution of students according to their status of 51 living 50 49 47 48 30 33 45 46

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Figure

Page

No. Title No 11. Percentage distribution of students according to the history of 52 smoking or tobacco use in the family 12. Percentage distribution of students according to the previous knowledge regarding ill- effects of tobacco use 13. Percentage distribution of students according to the recreational facility at home 14. Less than Ogives of pre-test and post-test knowledge scores 61 54 53

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LIST OF ANNEXURES
Annexure No. Page No 1. 92 Title

Letter seeking and granting permission to conduct the research study

2. 3.

Letter seeking Permission to conduct the pilot study Letter granting permission to conduct the pilot study

93 94

4.

Letter seeking and granting permission to conduct the main study Letter seeking consent to validate the research tool and planned teaching programme

95

5.

96

6.

Acceptance form for validation of tool and planned teaching programme

97

7.

Letter seeking expert guidance to validate the research tool and planned teaching programme

98

8. 9.

List of Validators Consent form

100 102

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Annexure No. Page No Title

10. 103 Criteria checklist for validating the structured questionnaire 11. 106 Evaluation criteria checklist for validity of planned

teaching programme
12.

Blueprint for knowledge questionnaire on ill-effects of tobacco use among adolescents

108

13.

Tool for Assessment of Knowledge on ill-effects of tobacco use among adolescents

109

14.

Tool for Assessment of Knowledge on ill-effects of tobacco use among adolescents (Kannada)

116

15. 16. 17.

Lesson plan on ill-effects of tobacco use Lesson plan on ill-effects of tobacco use (Kannada) Master score chart 160

122 142

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Chapter 1 Introduction

1. INTRODUCTION
Investing in adolescents health and rights will yield large benefits for the generations to come
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Anant Kumar Adolescence is generally understood as the period of transition from childhood to adulthood and describes both development and sexual maturity. The term adolescent is derived from the Latin word adolescere which means to grow into maturity. It also means to emerge or achieve identity and is the most challenging and critical time of ones life2. Adolescents health is influenced by the strengths and vulnerabilities of individual adolescents and the character of the settings in which they lead their lives .1 Adolescents change their environments, as happens when they go away to school or college or to a new place to live or work. Environmental changes may bring about personality changes2. Although the adolescents are generally thought to be healthy, so many adolescents do die prematurely. Most mortality in adulthood has its roots in the adolescent period. WHO estimates that 70% of premature deaths among adults are due to behaviours initiated during adolescence. The effects of modelling, imitation
1 and identification on behaviour can be observed from early childhood . Various

studies have shown that children and adolescents are more likely to use substances if they have parents who provide model for substance use. Nicotine is one among the classifications of substance use and the main pharmacologic agent in tobacco3.

The tobacco plant has existed for thousands of years in South America. When Columbus landed in the new world on 11 October 1492, he was offered golden tobacco leaves as a courtesy, but he threw them away. Some of his followers picked up the leaves and brought them back to the old world in Europe. The Portuguese brought it to India about four centuries ago 4.The number of people in the age group of 18 years and younger in the world today is 2.4 billion, which is the largest generation
5 in history .One of the greatest causes of concern among adolescents is tobacco

addiction. Tobacco is the second major cause of death today in the world. According to the Centre for Disease Control and Prevention, USA, 80% of adult tobacco users started smoking as teens, 35% had become daily smokers by age 18. Tobacco use remains the leading cause of preventable death in the United States, with 4,30,000 deaths each year (one in five) attributable to tobacco use. Tobacco kills over 5 million people worldwide annually6. According to WHO, 2003, nearly 55,000 children join the club of tobacco consumers in the country every day, while 77 lakh Indian children even below 15 years of age, take tobacco on a regular basis. Nearly 5 million people die due to tobacco use every year and this figure will increase to 10 million by 2020. Of these, 7 million deaths will occur in the developing countries, mainly China and India5. India is the worlds second largest producer of tobacco. Everyday, about eight to nine lakh Indians die due to tobacco use. It was estimated in 1999-2001 that 5,500 adolescents start using tobacco everyday in India, joining the 4 million young people, under the age of 15, who already use tobacco regularly. Like other developing countries, the most susceptible time for initiating tobacco use in India is during

adolescence and early adulthood, ages 15-24 years. Most tobacco users start using tobacco before the age of 18 years, while some start as young as 10 years5. Every year 8,00,000 new cancer cases are registered; 3,20,000 of which are suffering from neck cancers, largely attributed to tobacco habits. While tobacco claims about 4.9 million deaths annually alarming one million of them are from India6. Since 1988, 31 st May has been observed annually as the World No Tobacco Day and is the only global event to call attention to tobacco dependence, which is being supported by WHO and Ministry of Health and Family Welfare6. The Global Youth Tobacco Survey (GYTS) supported by WHO and the Centres for Disease Control and Prevention (CDC) conducted during the years 20002004 in India is the first survey that provides state-wise data on youth (13-15 years).using any form of tobacco. Tobacco use was maximum in Nagaland (63%) and lowest in Goa (less than 1%). In the state of Maharashtra it was 13%. The highest consumption appeared to be in schools and colleges located in rural and semi-urban areas. Awareness level regarding the harmful effects of tobacco consumption was substantially low among children and young7. An epidemiological study (2006) was conduted to determine the prevalence of smoking and tobacco use among 13 to 18 years of school children in Jaipur. A total of 3,805 samples participated. Results revealed that 1.5% of the boys and 0.4% of the girls agreed to current tobacco use. Smoking cigarettes or beedis was present in 1.5% of the boys and 0.8% of the girls. Smoking or tobacco use was present in immediate

family of 42.1% of the boys and 30% of the girls, but was significantly more in families of children who used tobacco8. According to the Indian Council of Medical Research (2005) nearly 1,60,000 people develop cancer in India as a result of tobacco consumption. According to Tobacco Boards annual report 2000-2001, Karnataka with its share of about 25%, is the second largest cultivated state in the country. Mysore and Shimoga are the predominant districts. During the year 2000-2001 tobacco was grown in a total area of 40,012 hectare acres with an output of 41.98 million kgs (dry weight). This is more than double the quantum with reference to the crop marketed during the year 1990-91 when it was 10.58 million kg9. Thus it shows that prevalence of tobacco use is much and it is growing higher day by day. Also it begins at an early age in adolescence, and hence it is necessary to target this age group for prevention programmes.

Need for the study


Tobacco use is a significant contributor to many other health problems including coronary heart disease, lung disease, cancer, damage to the female reproductive system and injury to an unborn foetus (including low birth weight, stillbirth and a higher rate of infant mortality). It is therefore, necessary to prevent its consumption10 . Most of the people consume tobacco in the form of smoking and chewing and it is a serious growing problem. Tobacco belongs to the night shade family solanaceae and the genus Nicotiana named after Jean Nicot, French Ambassador to Portugal. Many varieties developed subsequently and South American variety N. tabacum is the

major source of todays commercial varieties. Tobacco is powerful addictive substance and found to be harmful to the health11 . Everyday, about 80,000 to 1,00,000 young people initiate smoking, most of them in the developing countries. Of 1000 teenagers who smoke today, 500 will eventually die of tobacco-related diseases; 250 in their middle age. Tobacco is the single largest preventable cause of death and disability worldwide5. A study to assess the effectiveness of substance abuse prevention programme at University of Michigan, USA. A social pressures resistance skills programme implemented by classroom teachers had been evaluated. This evaluation used data from 262 students who completed questionnaires and received the complete two-year intervention or no intervention. Repeated measures analyses of variance demonstrated that significant effects evident at seventh grade for alcohol use and misuse, as well as cigarette, cocaine, and other drug use were generally not maintained through twelfth grade. The findings suggested that the school-based intervention for prevention of substance abuse is an effective measure12 . A study was conducted to assess the prevalence and attitude towards tobacco use among 13-15 years school students in Bihar 2000. A two-stage, cluster sample design was used. Of the 2636 respondents, 71.8% (76.5% boys and 57.2% girls) were ever tobacco users. Of them, 48.9% had used tobacco before 10 years of age. The findings suggested that tobacco consumption is more prevalent among adolescents13 . A cross-sectional study was conducted to assess the role of knowledge regarding tobacco risk-taking attitude of peers and other influences on tobacco and areca nut use among adolescents in two schools of New Delhi of classes IX and XI.

The sample size was 596. The results showed that almost 42% of tobacco users started its use before the age of 12 years. Peer pressure, general stress and media were important influences. It was concluded that multi-pronged and concerted efforts targeting children at an early age are required to prevent tobacco and areca nut use among adolescents14 . A cross-sectional study on tobacco use among street children of Delhi. was conducted to find out the tobacco consumption habits and reasons for initiation and continuation of tobacco use by these children and to assess their awareness about the harmful effects of tobacco use in 2003 . A total of sixty boys were interviewed regarding knowledge about the harmful effects of tobacco; 50% of them had knowledge about lung problems, 23.3% had knowledge about cancer, and 28.3% were ignorant15 . A study was conducted on tobacco consumption in school going boys in the slums of Pune city. The study showed that the prevalence to tobacco use in school going children was 63.8% and it starts at the age of 12 years. These children undergo a lot of peer pressure to experiment with various forms of tobacco16 . A study was conducted on knowledge of students on cannabis and tobacco among 964 school students of Baroda. The tool was a questionnaire containing 20 items. Data were collected immediately after 45 minutes of drug abuse awareness programme. After seven days data were collected using the same tool. The study revealed that the majority of students had increased knowledge after the awareness programme. The drug abuse use was reported by 38% out of 964 students17 .

A cross-sectional study was conducted in a group of 467 adults in the age group of 25-40 years to assess the knowledge, attitude and practice of tobacco use and cardiovascular diseases in Thiruvanthapuram district of Kerala. The findings showed that 451 (96.6%) of the subjects knew that tobacco use is harmful for health, only 101 (22.5%) of the subjects knew that it causes cardiovascular diseases. The findings suggested that the subjects lacked knowledge regarding the harmful effects of tobacco use18 . A study was conducted on tobacco use among school children in Chennai city to find out tobacco control interventions and evaluation. A two-stage stratified probability sample of students in grades 8-10 corresponding to 13-15 years of age were selected from private, government-aided private and purely government aided corporation schools. Data were collected by a pre-tested, closed-ended selfadministered questionnaire. A total of 1255 students participated in this survey. Among them 64.4% were boys and 35.6% were girls. Prevalence was more among boys (46.3%) when compared to that of girls (31.6%). This study demonstrated that among 13-15 years old school going children in Chennai city, the percentage of current tobacco use was high. Hence, there was a need to conduct a teaching programme19 . Tobacco maluse begins at an early stage during adolescence before they are able to purchase cigarettes legally. Tobacco use, prevention and cessation, are important social justice issues affecting the poor, many ethnic minorities, youth and elderly. The current healthcare system provides minimal reward for cessation and providers lack of awareness about brief interventions and existing resources contribute to limited efforts in tobacco cessation interventions. Tobacco control,

including tobacco use, prevention, tobacco cessation and reduction of exposure to second hand smoke is central to health and wellbeing and is an important priority for nursing action. Involvement of nurses in delivering smoking cessation interventions can be very effective in promoting attempts to quit tobacco use20 . From, above facts, the investigator is of the opinion that the adolescents lack knowledge on tobacco use and its hazards. Hence, there is a need to conduct a teaching programme on ill effects of tobacco use among adolescents.

Statement of the problem


Effectiveness of planned teaching programme on the ill-effects of tobacco use among adolescents in a selected high school, Mangalore

Operational definitions
1. Effectiveness: In this study it refers to the extent to which the planned teaching programme on the ill-effects of tobacco use has achieved the desired effect as evident from the gain in knowledge score. 2. Planned teaching programme: In this study it refers to the systematically developed teaching programme including areas such as concept of tobacco, causes of tobacco use, types of tobacco, and forms of tobacco use, ill-effects of tobacco use, steps of giving up tobacco use and the benefits of quitting tobacco use. 3. Ill-effects: In this study ill-effects refers to a state of health of adverse effects of tobacco resulting in various health problems like oral cancer, lung

cancer, tuberculosis, anxiety, and depression, which occurs as a result of prolonged tobacco use. 4. Tobacco use: In this study tobacco use refers to various types of tobacco in the form of gutka, pan, beedi, cigarette & snuff. 5. Adolescents: In this study adolescents refers to children in the age group of 12-16 years studying in selected high schools of Mangalore. 6. Selected high school: In this study selected high school refers to those coeducation high schools imparting education in Kannada and English as the medium of instruction.

Assumptions
1. It is assumed that adolescents will have some knowledge regarding ill-effects of tobacco use. 2. Planned teaching programme will increase the knowledge about health hazards of tobacco among adolescents.

Delimitations
The study is delimited to adolescents: 1. 2. between 12 and 16 years of age. attending the selected co-education high school.

Hypothesis
H0: There is no significant difference between the pre-test and post-test mean knowledge score of students regarding ill-effects of tobacco use.

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H1:

The mean post-test knowledge scores of adolescents regarding ill-effects of tobacco use will be significantly higher than their mean pre-test knowledge scores.

Conceptual framework
A framework is an abstract of logical structure of meaning that guides the
21 development of the study and the body of knowledge . If the framework is derived

from a theory, it is a theoretical framework. A theoretical framework guides the investigator to know what idea needs to be collected and gives direction during the entire research process. Conceptualisation is a process of forming ideas which utilises and forms a conceptual framework for a particular study. It is the abstract logical structure (frame) which enables the researcher to link the findings to the nursing body of knowledge22 . Conceptual framework is interrelated concepts or abstractions that are assembled in some rationale scheme by virtue of their relevance to a common theme. Each conceptual framework proposes a different view of the metaparadigm concepts which provides clear descriptions of variables, suggesting ways or methods to conduct the study and guiding the interpretations and integration of the significant findings23 . The conceptual framework for the present study is based on Penders Health Promotion Model which was developed in 1996. This model is based on four factors: 1. Individual characteristics: The importance of an individuals unique

characteristics and experience will depend on the target behaviour for health promotion. Some characteristics can influence health behaviours while others cannot be changed. Prior related behaviour includes experience, knowledge and skill in health promotion action. Individuals who made a habit of a

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previous health promoting behaviour and received a positive benefit as a result will engage in future health promoting behaviours. The researcher in this study has considered the prior related behaviour as the previous knowledge, unawareness, ignorance and traditional beliefs. The non-modifying factors include age, sex, education, family type, and place of stay of the adolescent. 2. Cognitive perceptual factors: Cognitive perceptual factors constitute a critical core of interventions because they can be modified through nursing care. This set of variables is considered to be of major motivational significance for acquiring and maintaining health promoting behaviours. The cognitive perceptual factors in the present study include the perception regarding the ill-effects of tobacco use and the perception regarding the benefits of quitting tobacco. The cues to action here includes here includes the mass media, campaigns, newspaper articles, advice form others and elders. Thus, in the present study, it is seen that the adolescents knowledge regarding the ill effects of tobacco is influenced by various cues. 3. Likelihood of action: Likelihood of action involves commitment and identification of specific strategies for carrying out and reinforcing the behaviour. The likelihood of a person taking recommended preventive health action depends on perceived benefits of preventive action minus the perceive barriers to the action.

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12

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In the present study likelihood of action includes the assessment of pre-existing knowledge of the participants, using a structured questionnaire, Adolescents implementing the teaching programme on ill effects of tobacco use, and again
Individual Cognitive Likelihood assessing the knowledge using the same structured questionnaire. Behavioural characteristics and perceptual of outcome experience factors action

4.

Behavioural outcome: Health promoting behaviour, the outcome of the

Assessment of Perception regarding attaining positive health outcomes prePrior related behaviour health promotion model, is directed towardsill-effects of existing knowledge tobacco Modifying factors using structured HealthPrevious the client. for knowledge Gain in Cues to action questionnaire promoting knowledge Unawareness and behaviour Mass media campaign ignorance Implementation of Advice from others In the Traditional beliefs present study, the behavioural outcome is explained by planned teaching Newspapers or magazine articles programme Maladaptive highlighting the Non-modifying factors gain in knowledge about the ill-effects of tobacco use and No gain in Perception regarding benefits of behaviour leading Age knowledge quitting tobacco to ill health Assessment of adopting health promoting activities to combat tobacco abuse. Sex knowledge following Cues to action Education teaching programme Advice from elders Family type using the same Newspaper or magazine articles structured Place of stay questionnaire Mass media campaigns

Chapter 2 Objectives

Not included in the study

Feedback

Figure 1: Modified conceptual framework based on Penders Health Promotion Model (1996)

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2. OBJECTIVES
Identification of a destination before undertaking a journey Weinback The research problem serves as the foundation of a research study. A research study begins with a problem that a research would like to challenge, ask questions that a researcher would like to answer, which often evolves from a broad area. The objectives provide the investigator with some clear criteria against which the proposed research method can be assessed57 . For the present study, a review of literature, consultation with experts and colleagues, and personal experience of the investigator gave a basis for selection of the problem. Thus the problem selected is Effectiveness of planned teaching programme on the ill-effects of tobacco use among adolescents in a selected high school, Mangalore. The objectives of the study are to: 1. identify the pre-existing knowledge of adolescents regarding the ill-effects of tobacco using a structured questionnaire. 2. design and administer a planned teaching programme on the ill-effects of tobacco. 3. find the effectiveness of teaching programme using the same structured questionnaire.

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Chapter 3 Review of Literature

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3. REVIEW OF LITERATURE
A review of literature is a comprehensive description as well as an evaluation of the evidence related to a given topic.25 Research is an ongoing process that builds on previous knowledge. A review to literature is necessary to narrow the problem to be studied. The review of literature involves locating theoretical or conceptual formulations that will help guide the study26 . The term literature review is used in two ways by the research community. The first refers to activities involved in identifying and searching for information on the topic and developing and understanding of the state of knowledge on that topic. The term is also used to designate a written summary of the state of the art on a research problem. Both the search and write-up are important in the research process. The task of reviewing research literature involves the identification, selection, critical analysis and written description of existing information on the topic of interest27 . The review of literature in this study is presented in the following headings: 1. 2. 3. 4. 5. The concept of tobacco use. Causes of tobacco use. Prevalence of tobacco use. Ill-effects of tobacco use. Effectiveness of teaching programmes for adolescents.

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1. Concept of tobacco
The word tobacco is derived from a Spanish word tobaca which is a Y shaped instrument used by early American Indians to inhale snuff by various types into the nostrils. The two active principles nicotine and nicotianine are found in the leaves of the plant Nicotiana tabacum. The addictive property of tobacco is due to one of its component alkaloids, nicotine28 . Nicotine the active alkaloid of tobacco is the principle addictive drug found in tobacco smoke. Nicotine affects a person slowly and makes him an addict and the person continues to smoke to maintain the nicotine level in the bloodstream; it increases heart rate and the blood pressure and constricts blood vessels hampering blood flow to the vital organs29 .

Types of tobacco products


By the end of the twentieth century manufactured cigarettes became the predominant form in which tobacco is consumed around the world. It is also consumed in many other forms. Tobacco can be of smoking variety or smokeless variety. Tobacco smoking is a widespread habit in most cultures and societies throughout the world. Tobacco is smoked either as a cigarette, cigar or in a pipe Major forms in which tobacco products commonly used are as follows: 1. Smoking tobacco a. Cigarettes: These may be manufactured or roll-your-own (RYO) cigarettes. Manufactured cigarettes are available in all countries.

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b.

Bidis: It consists of shredded, sun dried tobacco in small quantity that is hand rolled into a piece of tender and tied with a small string. These are popular in India.

c.

Cigars: These are made of air-cured tobacco which is dried naturally in sunlight. Cigars are of various sizes. Compared with cigarette smoke the concentration of toxins and irritants are higher in cigar smoke. Cigars comprise of both manufactured and local users in India.

d.

Chuta: This is a home-made cigar in Andhra Pradesh. It is made of cured tobacco wrapped in a dried tobacco leaf. In some areas of the state it is smoked with the lighted end in the mouth. This is described as reverse smoking.

e.

Cigarillo: It consists of cigar tobacco wrapped in treated cigarette paper. It is also called as cigarette-like cigar.

f.

Pipes: Pipe smoking was one of the earliest forms of tobacco smoking. In India chillum is used while in Nepal sulpa is used. Water pipe, which is also known as hookah, goza or sheesha is used in Middle-east, Asia and parts of Africa.

2.

Smokeless tobacco a. Chewing tobacco: The local brands differ from regions to countries. In India different forms of chewing tobacco are used. Such as pan chewing, zarda, snuff, mishri, and gutka. In India, chewing tobacco is mostly consumed by adolescents and females.

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b.

Pan chewing: It is popular in South Asia, especially in India. Pan is also known as betel leaf. The main ingredients wrapped in betel leaf are tobacco, dried leaf, areca nut and slaked lime. There are many regional variations in the form of the tobacco used in the pan. .

c.

Zarda: This is used in India and Arab countries. Tobacco leaf is boiled with spices and lime till evaporation; the residual tobacco is then dried and coloured.

d.

Snuff: It may be dry or moist. A moist type of snuff is available in North America and Europe. Snuff is used either orally or nasally. Most snuff is taken orally. In India it is also used at tooth cleaning agent. Snuff is the finely powdered plant material. In North America snuff is just placed in the mouth along the gum in the lip fold or the buccal fold; sometimes it is placed under the tongue.

e. f.

Mishri: This is powdered tobacco which is dark roasted. Gutkha: It is sweetened mixture of tobacco, betel and catechu which is chewed together. It is widely consumed by women and children. More and more children are consuming gutkha as the small coloured sachets easily attract them30 .

2. Causes of tobacco use There are some factors contributing to tobacco use among the adolescents and youth2.

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The common reasons among adolescents for using tobacco products are peer pressure, glamour created by heroes in movies, curiosity and experimentation. Feeling of insecurity and anxiety often prompt a person to start smoking which is viewed as harmless and a safer option when compared to hard drugs. Tobacco companies have been steadily increasing spending on promotion, specially targeting the youth. Advertisements focus on cigarette brands and a particular quality of life specially reinforcing a macho image. This has definitely increased tobacco consumption among youth. Some chewers have been dipping so long that they miss the ritual of opening the chewing pan, getting the dip and putting it in their mouth. The most common statement heard from these users is I just miss something in my mouth. i.e., oral gratification. Other factors include general rebelliousness, poor impulse control, unmet needs, poor social support, urbanisation, easy availability etc. Role model shown by the parents, particularly a smoking father or a tobacco chewing mother, has been observed as an influence for initiating into tobacco use. A cross-sectional study was conducted in America on the joint influence of parental modelling and positive parental concern on cigarette smoking in middle and high school students. A total of 37,244 students participated. The purpose of this study was to examine the interaction between parental smoking status and parental

20

attitude as measured by positive parental concern on the risk of adolescent cigarette smoking. Parental concern was classified into three levels strict, moderate and minimal. The likelihood of youths being current smokers was positively associated with both parental smoking and less parental concern. The result revealed that minimal parental concern about smoking worsens the risk due to parental modelling. The findings shown that among 37,244 students, 78% were never smokers and 22% were current smokers31 . A descriptive study to assess the smoking habits among the medical students and its relationship to the demographic social and psychological characteristics was conducted in GSVM Medical College, Kanpur to study the smoking trends and psychological factors. A total of 1293 students were taken as a sample and the result reveals that the two groups as married group had more smokers (44.3%) than the unmarried group (29.1%) and there were more smokers from rural background, 82 cases (35%) as compared to the students of urban area 181 (29%). Thus the author concluded that the psychological factors like failure of intimacy led to higher percentage of smoking32 . A community-based study was conducted on smoking mothers in the prediction of affective vulnerability among young adult daily workers in Burlington, USA 2005. A total of 276 young adults participated. The results revealed that the motivation to smoke was significantly high related to anxiety sensitivity and negative affectivity. The findings suggested that there are important association between certain smoking motives and negative affective states33 . Survey was conducted in Sikkim during January-march among 13-15years of students using anonyonous self-administered questionnaire. The overall response rate

21

was 85% and the proportion of the boys were 55% current smokeless tobacco and gutkha use and exposure to gutkha advertisements was reported equally for both boys and girls. Current smokeless tobacco users than never tobacco users were likely to watch actors chewing tobacco on TV, video, or movies (90.4%); to watch gutkha brand names on TV sporting events or TV programmes (63.1% Vs 36.2% ); to watch gutkha advertisement on hording at bus stops etc (63.8% Vs 33.9%); and gutkha advertisements in gutkha advertisements in the community events (65%Vs 38.7%)34 . 3. Prevalence of tobacco use A survey was conducted on tobacco use among urban youth of Massachusetts in 1999. A total of 642 respondents participated in the study. The result revealed that 42% had smoked beedi at least once in the lifetime. Sixteen percent were current beedi smokers. The finding suggested that tobacco use among urban youth was prevailing high in Massachusetts35 . A study was conducted on the prevalence and pattern of substance abuse at Banderdewa border area of Assam and Arunachal Pradesh. A total of 312 adolescents aged 10 years and above were interviewed to collect the information about their habits of taking tobacco substances. The study revealed that 52.2% were only tobacco chewers, 26.3% were smokers, and 15% were practising both the modes; the gender ratio of tobacco use was higher in males (50.2%) than in females (26.7%).36 A comparative study was conducted to examine tobacco use among Alaska native youth. A total of 665 youth in the age group of 6 to 18 years were taken as the sample. The result revealed that the prevalence rate of tobacco use was significantly higher in females as compared to males37 .

22

A study to assess the changes in prevalence of tobacco use among 11,642 students in the sixth and eighth grades between the age group of 10 to 16 years was conducted in the year 2006. The study was carried out in 32 government and private schools of Delhi and Chennai. The study revealed that students who were in government schools, males, older and in sixth grade were more likely to use tobacco than students who were in private schools female, younger and in eighth grade. The finding shown that sixth grade students used significantly more tobacco than eighth grade students38 . A comparative study to examine the relationship between the school policy and tobacco use among 6,587 students in Bihar (2636 students from state school) and (3951 students from federal school) was conducted. The result shown that the students in state school (72.8%) were significantly more likely than the students in federal school (35.6%) for tobacco use39 . A cross sectional study was conducted in rural area of Bihar using structured schedule by interviewing 9097 subjects. The response rate was 91%. Among 3566 children (<15years), smokeless tobacco use was 6.2% and smoking was 0.3%. Most smokeless tobacco use was in the form of red tooth powder (77%) smokeless tobacco use among adults was 32.7% smoking prevalence was 27.7%. The most prevalent form (>81%) was smoking both in men and women40 . Information on tobacco was obtained from the 609 students of 8
th

, 9 th , and

10th grade of pittsburg area using a questionnaire. The data disclosed that 22% of girls and 11% of boys were smoking , 35% of the young men reported using smokeless tobacco, snuff and /or tobacco chewing (19%). Sixty four percent of the smokeless

23

tobacco users indicated that it is less harmful than smoking. Sixty three percent of this group first learned from friends or relatives but only 4% from advertising media41 . 4. Ill-effects of tobacco use The single greatest risk factor for oral cancer is tobacco. All forms of tobacco have been implicated as causative agents, including cigarette, cigar and pipe tobacco as well as chewing tobacco. Tobacco use is the leading preventable cause of death globally causing five millions deaths a year. Evidence shows that smoking harms nearly every organ of the body. It is the cause of 90% of lung cancer cases and is linked to many other types of cancer such as cervical or kidney cancer as well as emphysema, bronchitis, asthma and other respiratory diseases. Other health risks associated with tobacco use include other types of cancer such as oral, throat and neck cancer as well as heart attack, stroke, other cardiovascular diseases and infertility42 . A cross-sectional study was conducted on smoking and tobacco use at Jaipur. A total of 5360 subjects were observed for tobacco consumption. The results revealed that the greatest tobacco consumption was among illiterate and low educational status people and smoking leads to acute respiratory diseases, tuberculosis and asthma in younger age group. So the author concluded that cessation of smoking is an appropriate measure to prevent the epidemic of non-communicable disorders43 . A survey was conducted on the prevalence of asthma in the different schools of Chandigarh. A total of 9090 students in the age group of 9-20 years were analysed. The results revealed that 41% of students having asthma gained it from family

24

members smoking at home and there was significant evidence in favour of environmental tobacco smoke exposure as a risk factor of asthma is 59%.44 A prospective study was conducted by International Agency for Research on Cancer in ten European countries to investigate the association between

environmental tobacco smokers and risk for respiratory cancer. A total of 5 lakh samples were studied for 7 years. The result shows that 97 people had newly diagnosed being cancer 20 had upper respiratory cancer and 14 died from COPD. In the whole cohort exposure environmental tobacco smoke was associated with increased risk for all respiratory diseases. In conclusion, this large prospective study supported that environmental tobacco smoke is the risk factor for lung cancer and other respiratory diseases45 . A survey was conducted in 3 schools of the Washington, among 6
th

,9th ,11th

grade students to assess their attitude towards tobacco use. 34% of male native American, 24% of females, 20% of male non natives and 4% of females non natives are current users of smokeless tobacco products. The number of the friends having smoked cigarette, use by siblings and use by relatives and used by father greatly contributed for males initiation of smoking. In females the most important variables was friends. Reason for starting to use and continuing smokeless tobacco related to pleasure, taste, peer pressure and addiction. Principal reason nonsmoker gave for not trying was it focused on health issue and the unpleasant smell and appearance of smokeless products.46 A study on knowledge, attitude, and practice with regard to tobacco usage was conducted among 1278 boys and 353 girls in Bombay of various schools. Large

25

proportion of boys in all schools smoked if their fathers smoked. Those whose best friend was smoker were significantly more often smokers than whose friends were not (private English Medium-56.5%Vs 14.3% , private Indian language 33.3% Vs 2.6% ; Municipal Indian language 42.4% Vs 5.3%). Most smokers in private English schools did not want to accept that smokers die usually younger than non-smokers. Municipal Indian language school boys, who smoke, generally seem to be aware about the risk run by the babies of women who smoke or harmfulness of passive smoking. In general knowledge regarding risk of specific diseases due to smoking was poor. 50% of smokers in private Indian school agreed that smoking does make them feel good. Smokers from private Indian school agreed that smoking makes them feel and appear grown up. Almost 50% of the children felt that a ban on cigarette advertisements or smoking in public places or hike in cigarette prices was not warranted.47 A study was conducted to find the prevalence of tobacco use among the school and college going adolescents of Ballabgarh, Haryana. Children from class viii to xii, college students in the arts and commerce discipline (male n=1130 and females n=256) were the subjects for the study who were given a self-administered questionnaire regarding tobacco use. The study revealed that a total of 166(12%) students had ever smoked. About 6% of the children in the age group 13-14 years had ever smoked which increased to around 15% among those of age 18 years or more. The prevalence in males was 14.2% compared to 2.3% in females. The study also revealed that about 80% of the samples were aware of the adverse effects of smoking.48 A descriptive survey conducted in parts of rural southern Tamilnadu, rural Gujarat and semi-urban area in Bangalore. A internationally developed English

26

questionnaire was administered to the students. The study revealed that the students were aware of harmful effects of smoking (68%boys and 94%girls) whereas only 44% of boys and 53% of girls were aware of harmful effects of chewing tobacco49 . 5. Effectiveness of teaching programme Tobacco is a major preventable cause of disability and premature death in the US. According to the WHO tobacco is also the second major cause of death globally and will kill approximately 10 million people annually worldwide by 2020. Tobacco affects almost every body system. WHO has urged countries to adopt stringent measures including a ban on public smoking, to stop potentially dramatic rise in tobacco-related deaths among young ones. Every year since 1989, 31
st

of May is

observed as World No Tobacco Day to sensitise the government, communities, groups and individuals to become aware of the problem and take appropriate action.50 The various methods to stop smoking are health education, social upliftment, strict punishment, banning tobacco-related advertisements on television, etc. Knowledge related to smoking and its ill-effects on health should be disseminated through organised campaigns and planned teaching programme. A training programme was conducted on anti-smoking activities to the group of tenth grade students at a high school in Ankara, Turkey(2007) . A total of 252 students participated in the education and training programme and the result revealed that the education training programme was successful in changing the knowledge and attitude regarding smoking among the school students and thus the researcher concluded that peer counsellors, well-trained and with ongoing supervision, can have a positive effect on the knowledge and attitude about smoking among their friends51 .

27

A quasi experimental study was conducted to evaluate the effectiveness of planned teaching programme regarding the adverse effect of tobacco smoking on knowledge gain of 10
th

standard in a selected school of kolar district in Karnataka.

Sample (n=30) were chosen by convenient sample technique. The tool used were a structured knowledge questionnaire to assess students prior information, followed by a planned teaching programme. The study finding revealed a significant difference between pre-test and post test knowledge scores(t value 19.18, p< 0.001) suggesting effectiveness of PTP in increasing the knowledge of students regarding the adverse effects of tobacco smoking52 . A study was conducted on effectiveness of PTP on awareness regarding promotion of mental health among adolescents in a selected college at Mangalore. The finding of the study showed that total mean percentage of the pre-test score was 46.11% with total mean and SD 17.52+-6.05where as total mean percentage of the mean and SD of 30.45+-4.02 which showed an increase of 34.03% in mean knowledge of adolescents after planned teaching programme. The findings showed that there was significant increase in the post- test knowledge scores compared to the pre-test knowledge score among adolescents53 . A study on effectiveness of school-based drug prevention programmes for Marijuana use in 37 schools of America between grades 6 and 12 was done by coding programme characteristics and calculating weighed effects sizes (WES). Programmes were divided into two types, interactive and non-interactive programme. Least squares multiple regression analysis was performed using the WES of Marijuana use as dependent variable, type of programme as the predictor. The result revealed that non-

28

interactive lecture oriented programme was less effective in the reduction of Marijuana use54. An evaluatory study to assess the effectiveness of substance abuse prevention programme at university of Michigan, USA. A social pressures resistance skills programme implemented by class-room teachers was carried out. This evaluation used data from 262 students who completed questionnaires and received the complete two year intervention or no intervention repeated measures analysis of variance showed that significant effects evident at seventh grade for alcohol use and other drugs use were generally not maintained through twelfth grade. The finding shows that the school based interventions for prevention of substance abuse is an effective measure12 . Chen H and Yeh M conducted a comparative study to assess the effectiveness of a smoking cessation programme for adolescents. A total of 77 high school students were divided into two groups. One group, designated as the experimental group, accepted a 6-week smoking cessation programme and the other group did not. All participants completed the questionnaire before and after the programme. The findings showed that the strategy of smoking cessation programme was highly effective in terms of effects upon the youths attitude towards smoking, smoking behaviour and self-efficacy.55

29

Chapter 4 Methodology

29

METHODOLOGY
Genius is the ability to reduce the complicated to simple Research methodology is a way to systematically solve the research problem. It describes various steps that are generally adopted by the researcher in studying the research problem along with the logic behind them and explain why he uses a particular method or technique so that research results are capable of being evaluated by him or by others. The methodology of the research study indicates the researchers overall plan for obtaining answers to research questions and it spells out the strategies that the researcher adopts to develop the information that is accurate, objective and interpretable56 . Research methodology includes research design, approach, settings, population, sample, sampling technique, development, and description of the tool, pilot study, method of data collection, and plan for data analysis. The present study aimed at evaluating the effectiveness of planned teaching programme on Ill-effects of tobacco use among adolescents in a selected high school, Mangalore; in terms of their gain in knowledge scores.

Research approach
Research approach indicates the basic procedure for conducting the study. The selection of approach depends upon the purpose of the study. The present study aimed at determining the effectiveness of planned teaching programme on Ill effects of tobacco use. In view of the nature of the problem selected for the study, an evaluative approach was found appropriate. Evaluation research is an applied form of research that involves finding out how well a programme, procedure or policy is working. Its goal is to assess or evaluate the success of a programme27 .

30 32

31

SettingAn evaluatory research is commonly conducted to rate the extent to which a


programme has attained its goal. The location for conducting the research is referred to as the setting58 .

Research design
Population

Pre-test (x) The present Sampling conducted insetting study was Pompei high school, Mangalore city. Research design spells out the basic strategies that the researcher adopts to technique

Sample &

Research

Post-test (y) Analysis Treatment

develop information that is accurate and interpretable27 .

Variables

questionnaire

Day 6 DescripDay 1 pre-test school educational Assessment of studying in tive and Independent variable: The considered very weak in which manipulated or experimental designs that arevariable which can be purposely the researcher has little knowledge students high school PTP on post-test selected high inferenWith in illknowledge with school, Structured Simple control over the by the researcher. Here Mangalore post test design provides pre test the independent sameeffects tial structured Mangalore changed research. The one groupIll-effects of tobacco use isknowledge a statistics random of knowledge questionnaire li comparison between a group of subjects before and after the experimental treatment. tobacco variable.

A research design is essentially a plan or strategy aimed at enabling answer to Research variables are concepts at various levels of abstraction that are be obtained to research questions. measured, manipulated and controlled in a study58 . Day 1 Pre-experimental design is a named applied by Campbell Assessment of and Stanley(1963) to 50 high Selected coAdolescents

Dependent variable: Change occurring as a result of manipulation of independent

In view of the nature of the problem and to accomplish the objectives of the

study, with a one group pre-test post-test pre experimental design was used to variable. Here change in knowledge is the dependent variable. evaluate the effectiveness of the planned teaching programme on Ill effects of tobacco use among adolescents in a selected high school. The design did not include any Figure 2: Schematic representation of the Research methodology Population control group. Population is the entire group of people, objects or events which have at least The study design shows that on the first day, pre-test was given to assess the one characteristic in common and must be defined specifically and unambiguously59 . existing level of knowledge of high school students on ill- effects of tobacco use, using a The population for the study comprised of Adolescents between alsoage group structured questionnaire. The planned teaching programme was the of 12-16 studying insame dayhigh school, Mangalore. the seventh day post- test administered on the selected following the pre-test. On was conducted to assess the gain in knowledge using the same structured questionnaire. The study design is schematically represented as follows Treatment Pre-test --------------------------Post-test = Effectiveness (X) (Y) (Y-X )

33

Sampling Procedure Sample and sample size


A sample is a subset or portion of the population that has been selected to represent the population of interest60 . The present study was conducted among 50 high school students in Pompei high school between the age group of 12-16 years who met the sampling criteria.

Criteria for selecting the sample Inclusion criteria


Adolescent both male and female students who were: studying in a high school in the age group between 12-16 years willing to participate available during study period.

Exclusion criteria
students who were not willing to participate in the study . Students who were absent in the day of data collection.

34

Sampling technique
Sampling is a process of selecting a group of people, events or portion of the population to represent the entire population61 . Random sampling is a probability sampling which involves a selection process in which each element in the population has an equal and independent chance of being selected27 . Simple random sampling was used for the present study for the location of the college and selection of the subjects. Mangalore city has fifty-two co-educational high schools. In first stage simple random sampling method, i.e. lottery method was opted for selecting a school. Thus Pompei high school was selected randomly which is three and half kilometre away from railway station, Urwa, Ashok nagar near Ladyhill. In second stage random sampling using lottery method, 15 students from eighth grade, 20 students from ninth grade and 15 students from tenth grade were selected who were fulfilling sampling criteria.
Pompei High School

15 students from eighth grade

20 students from ninth grade

15 students from tenth grade

50 adolescents

Figure 3: Schematic representation of sampling procedure

35

Development of the data collection tools and technique


The instruments selected in a research must be the vehicle that obtained the best for drawing conclusion to the study59 . The study was aimed to evaluate the effectiveness of planned teaching programme regarding Ill-effects of tobacco use among adolescents studying in a selected high school. Planned teaching programme followed by administration of structured knowledge questionnaire was considered as an appropriate and effective method to evaluate the knowledge of the subjects. The steps followed in the development of tool were: Review of research and non research materials was made in the areas relevant to concept of tobacco, causes of tobacco use, ill effects of tobacco use, benefits of giving up tobacco and the ways to give it up. Opinion and suggestions from the experts in the field of medicine, psychiatry and nursing were taken in determining the important areas to be included.

Description of the tool


A closed ended structured questionnaire was prepared to collect the necessary data from the samples. The same tool was translated in Kannada also, as the randomly selected high school is having Kannada as a medium of instruction. The questionnaire had two parts. Part I: It consists of eleven items regarding demographic characteristics of the students and was developed to collect the background information of

36

students. The items included in the demographic proforma are age, sex, family type, religion, occupation of parents, monthly income of family, marital status of parents, status of living, history of smoking or tobacco use in the family, previous knowledge regarding the ill-effects of tobacco, recreational facility at home. Part II: This part contains a checklist with total of 35 statements which includes four statements from concept of tobacco, four statements from causes of tobacco use, three statements from types and forms of tobacco, seven statements from physical ill effects of tobacco use, seven statements from psychological ill effects of tobacco use, three statements from benefits of tobacco use and four statements from steps in giving up of tobacco use. Thus altogether there were items with maximum score of 35. Each correct answer carries a score of one and zero for wrong answer.

Preparation of the blueprint


A blueprint on the knowledge questionnaire was prepared consisting of three sub areas. It depicted the distribution of items according to the content areas based on three domains, namely, knowledge, comprehension and application. Knowledge domain had 7items (20%), comprehension had 14 items (40%) and application had 14 items (40%) covering all the aspects of ill effects of tobacco use.

Content Validation of the tool


Validity is a measure of truth or accuracy of a claim and is an important concern throughout the research process. It refers to whether a measurement instrument accurately measures what it is supposed to measure61 .

37

Content validity refers to the adequacy of the sampling of the domain being studied62 . The content validity of the tool was established in consultation with nine experts in the field of Medicine, psychiatry, and nursing. Experts were requested to give their opinions and suggestions regarding relevance, appropriateness, accuracy and degree of agreement in each item of the tool. Suggestions and recommendations given by the experts were accepted and necessary corrections were done for modifying the tool.

Reliability
Reliability of a research instrument is defined as the extent to which the instrument yields the same results on repeated measures61 . To establish reliability, the tool was administered to ten students other than the study sample selected randomly from government high school, Mallikatta. Split half method was used to test the reliability of the tool. The tool was first divided into two equal halves with odd and even number of questions. Correlation of the test was found out using Karl-Pearsons correlation coefficient formula.

It shows that there is a significant correlation between the scores. The reliability coefficient of the whole test was then estimated using Spearman Brown Prophecy formula. The tool was found reliable (r = 0.8176).

[n]x [

n xy y =x
2

(x) 2 ny 2 (y) 2

38

Development of planned teaching programme


Teaching plan is a guide for the teacher because it helps to cover the topics comprehensively with proper sequence of points and without missing anything64 . The steps to prepare teaching plan were: Review of literature. Framing the outline of the content. Preparation and organization of content. Deciding the method of instruction and AV aids. Development of criteria checklist Ascertainment of the content validation of the PTP. Preparation of the final draft Editing the teaching plan. Evaluating the teaching plan.

Review of literature
An extensive literature review was undertaken regarding concept of tobacco, forms and types of tobacco use, causes of tobacco use, and ill effects of tobacco use, from the research and non research material, internet sources, journals etc.

39

Framing the outline of the content


The outline of the teaching plan was framed which included setting up the general and specific objectives, specifying the date, time, place and size of the group, number of sessions, and duration of sessions.

Preparation and organisation of the content


Content of the planned teaching programme was prepared and organized under various headings according to the specific objectives.

Ascertainment of the content validity of the planned teaching programme


Content validation of the PTP was ascertained in consultation with the experts in the field of Medicine, psychiatry, nursing, English and kannada. Suggestion and recommendation of the experts were considered to modify the content of planned teaching programme.

Development of criteria checklist


The criteria checklist was developed to evaluate the teaching plan based on the criteria stated. It was consisted of six items under the headings of objectives, content, organisation, presentation, language and practicability. It was sent to experts to give their opinions and suggestions regarding the relevance, appropriateness, accuracy and degree of agreement in each item of the planned teaching programme.

Deciding the method of instruction and AV aids


The method of instruction adopted was lecture-cum-discussion. Audiovisual aids were prepared in charts, posters and flash cards.

40

Preparation of the final draft of PTP


General and specific objectives of the teaching plan were given in the beginning of the PTP. Final draft of planned teaching programme was organized under various headings such as concept of tobacco, causes of tobacco use, types and forms of tobacco use, ill effects of tobacco use,

benefits of giving up tobacco and the ways to give it up.

Editing the teaching plan


The prepared planned teaching programme was edited by professional editors.

Pilot study
Pilot study is a version of the proposed study conducted to refine the methodology. It was developed similar to the proposed study, using similar subjects, the same setting, the same treatment, the same data collection method and the same analysis technique57 . Pilot study was conducted in government high school, Kavoor to find the feasibility of the study. Five adolescents who possessed the same characteristic of the sample for the final study but other than the samples selected for the final study were selected by simple random sampling technique. Prior to the data collection, permission was obtained from the concerned authority. The selected samples were informed of the purpose of the study and the consents were taken. To assess the knowledge, questionnaires on ill-effects of tobacco use were distributed to five students on 23
rd

August 2007 with an instruction to complete and

41

return them. Planned teaching programme on ill- effects of tobacco use was administered on the same day following pre- test. A post-test was conducted by administering the same questionnaire after six day of pre-test and administration of PTP. The completed questions were collected after 45 minutes. The collected data were analyzed by using descriptive and inferential statistics. Assessment of level of knowledge of the students regarding ill- effects of tobacco use revealed that 70.50% of the respondent had average knowledge, 12.60% had good knowledge and remaining 16.9% had poor knowledge regarding ill effect of tobacco. The mean SD of pre test was 17.33 1.73 with a mean percentage of 50.97% where as post test was 29 1.67 with mean percentage of 85.29%. The effectiveness of PTP was 34.39%which shows an increase in knowledge after administration of PTP. The significant deference between pre test and post test was found by using pairedt test. The difference was found very highly significant (t=10.09, p<0.005). The purpose of the pilot study was to find out the feasibility of the study, clarity of the language in the tool as well as in the planned teaching programme and to finalize the plan for analysis. After conducting the pilot study, it was found that the study was feasible, the concerned authority and the samples were found to be co-operative, the questionnaire and PTP were relevant and the time and cost of the study was within the limit.

Tool to evaluate the effectiveness of PTP


The same closed ended knowledge questionnaires which had been used to estimate the knowledge of ill- effects of tobacco use, was used to evaluate the effectiveness of the PTP by measuring gain in knowledge.

42

Data collection procedure


Before collecting the data prior permission was obtained from the concerned authority of the selected high school. Keeping in mind the ethical aspect of research data collected after obtaining informed consent of the sample. The respondents were assured the anonymity and confidentiality of the information provided by them. The researcher herself collected the data from the subjects. Pre-test was conducted on 23
rd

August 2007 followed by planned teaching

programme administration. The duration of the session was one hour. After the session different doubts were clarified by the researcher. After 6 days on 29 2007 the post-test was conducted using the same questionnaire to evaluate the effectiveness of the planned teaching programme.
th

Aug

Plan for data analysis


Descriptive statistics are useful for summarising empirical information. Inferential statistics which are based on laws of probability provide a means of drawing conclusion about the population from which data was obtained for the sample63 . Data will be analysed using descriptive and inferential statistics. First of all the data will be arranged in master sheet. Description of the subjects with respect to demographic variables will be presented using frequency and percentages. Mean, standard deviation, and mean percentages will be used to evaluate the effectiveness (X2-X 1) of PTP. Further statistical significance of the effectiveness of the PTP will be analyzed by using paired t test. Data will be presented in tables, graphs and

43

diagrams. The level of knowledge will be grouped into poor (<40), average (40-70), and good (>70).

Summary
A one group pre- test and post -test pre-experimental design with evaluative approach was adopted in order to evaluate the effectiveness of PTP regarding illeffects of tobacco use among 50 students of a selected high school at Mangalore. Closed ended knowledge questionnaire was used to assess the knowledge regarding ill- effects of tobacco use. Validity and reliability of the questionnaire and PTP were tested. Pilot study was conducted to find out the feasibility of the study. Data were collected from the sample after obtaining permission from the concerned authority. Collected data will be analysed using descriptive and inferential statistics and presented in the form of tables, graphs and diagrams.

44

Chapter 5 Results

44

RESULTS

The description of results is the heart of a research project. It is the communication of facts, measurements and observation gathered by the research worker65 . For achieving the research results the collected data must be processed and analysed in an orderly coherent fashion. The term analysis means the computation of certain measures that exist among data groups66 . This chapter deals with the analysis and interpretation of results of the data collected from the sample of 50 high school students regarding knowledge on concept of tobacco, causes of tobacco use, types and forms of tobacco use, ill effects of tobacco use, benefits of giving up tobacco, and the steps to give it up, keeping in view the objectives of the study. One group pre-test post-test pre-experimental design with an evaluatory approach was adopted to evaluate the effectiveness of planned teaching programme. The data was collected form the participants both before and after the administration of PTP. The gathered data was then organised, tabulated, analysed and interpreted using descriptive and inferential statistics. The results have been organised and presented in four parts: Part I: Part II: Description of demographic characteristics of the students. Analysis of pre-test knowledge of the students regarding ill effects of tobacco use. Section A: Assessment of the level of existing knowledge.

45

Section B: Section C: Part III:

Area-wise analysis of knowledge scores of the students. Item-wise analysis of knowledge scores of the students.

Evaluation of the effectiveness of PTP on knowledge on ill effects of tobacco use. Section A: Section B: Quartile of the pre-test and post-test knowledge scores. Area-wise effectiveness of the PTP on ill effects of tobacco use. Section C: Item-wise effectiveness of PTP.

Part IV:

Testing of hypothesis.

46

Part I: Description of demographic characteristics of the students


The entire sample comprised of 50 students a. Percentage distribution of students according to the gender

60.00% Male Female 40.00%

Figure 4: Distribution of students according to the gender

Distribution of the students according to their gender shows that 60% of the students were male and 40% were female.

48 47

c. b. Percentage distribution of students according to the type of family Percentage distribution of students according to religion

82.00% 50 40 Joint age 30 ercent P 20 10

92.00

Nuclear

4.00 0 00%

18.00% 4.00 -

Figure 5: Distribution of students according to the type of family 0

Distribution of the samples with reference to the type of family reveals that 82% of the students belonged to nuclear family and 18% to joint family.

49

d. Percentage distribution of students according to the occupation of their parents

90

90 80 70 e g ta n e c r Pe 60 50 40 30 20 10 0
8 2 0

Hindu otherMuslim Any

Christian

Figure 6: Religion-wise distribution of students Distribution of students according to their religion shows that a greater percentage (92%) belonged to Hindu religion, whereas (4%) were Muslim and the equal percentage (4%) belonged to the Christian.

50

e.

Percentage distribution of students according to the monthly income of

family Occupation of Parents

60 60 50 40 e g a t n e c r Pe 30 20 10 0

22 18

Private sector

Governmen t sector

Business

Agriculture
0

Figure 7: Distribution of students according to the occupation of their parents

The percentage distribution regarding occupation of parents reveals that highest percentage (90%) were working in private sector, (8%) were working in government sector and only (2%) were having their own business.

Monthly income of the family

< 5,000

5,001-10,000

10,001-15000

> 15,001

Figure 8: Distribution of students according to the monthly income of family

The distribution of subjects regarding monthly income of the family revealed that 60% had income below Rs. 5,000; 22% had income between Rs. 5,001-10,000 and only 18% had income between 10,001-15,000.

52 51

g. Percentage distribution of students according to their status of living f. Percentage distribution of parents according to marital status 74.00 60

45

96.00% Living together 18.00 8.00

age ercent Divorced 30 P 15 4.00%

0 Figure 9: Distribution of parents according to marital status

Distribution of parents related to marital status reveals that majority percentage (96%) of the parents of the students were living together and only 4% were divorced.

53

h.

Percentage distribution of students according to the history of smoking or tobacco use in the family

100 80 e g 60 a t rcen e P 40 20 0
s

62.00 38.00

Parents Grand parents Hostel

Relative

Figure 10: Distribution of students according to their status of living

Majority of the students (74%) were living with their parents, (8%) were living with their grand parents, (18%) were living with their relatives and none of them were staying in hostel.

54

i. Percentage distribution of students according to the previous knowledge regarding ill- effects of tobacco use

62 70 60 50 e g 40 a t cen 30 r e P 20 10 0 38

Yes

No

Family history of smoking or tobacco use in family

Figure 11: Distribution of students based on the family history of smoking or tobacco use Percentage distribution according to the family history of smoking or tobacco use revealed that in the majority of family (62%) of the students there was history of smoking and tobacco use. Only (38%) were not having family history of smoking or tobacco use.

Previous Knowledge Regarding Ill-effects of tobacco use

Yes

No

Figure 12: Distribution of students according to the previous knowledge regarding ill-effects of tobacco use

The percentage distribution of students regarding previous knowledge on illeffects of tobacco use revealed that majority (62%) were having knowledge and 38% were not having knowledge.

55

j.

Percentage distribution of students according to the recreational facility at home

Recreational facilities at home


14%

2% 8% TV DVD 4% 58% Peers 14% Radio Magazine Internet

Figure 13: Distribution of students according to recreational facility at home

The analysed data regarding recreational facility of the students reveals that highest percentage (58%) of the students were using TV, 14% had DVD, 4% had radio, 8% had magazines, 2% had internet and only 14% were playing with peers.

56

Part II: Analysis of pre-test knowledge level of the students regarding ill-effect of tobacco use.
Section A: Level of knowledge of students regarding ill-effects of tobacco use Table 1: Assessment of knowledge of the students regarding ill-effect of tobacco use Level of knowledge Poor < 40 Average Good >70 Percentage Percentage range of score 24 48 40 70 26 52 No. of respondents

Assessment of level of knowledge of the students shows that highest percentage (52%) of the students had average knowledge regarding ill-effects of tobacco use; and 48% of the students had poor knowledge regarding ill-effects of tobacco use.

57

Section B: Area-wise analysis of knowledge scores of the students Table 2: Description of area wise Mean, SD, Mean percentage of knowledge score N = 50 Sl. No. 1. 2 3 4 5 6 7 Knowledge SD Mean % area Concept20.5 of tobacco Causes of tobacco use 54.00 Types and forms of 47.33 03 1.42 0.642 tobacco use Ill effects of tobacco use 07 3.36 1.675 48.00 ( physical) Ill effects of tobacco use 07 3.70 1.446 52.857 ( psychological ) Benefits03 1.62 0.878 54.00 of giving up tobacco Steps in44.00 up tobacco giving 04 1.76 0.916 Max. possible score 04 04 Mean score 0.82 2.16 0.850 0.934

Analysis shows that adolescents had highest mean percentage (54%) of the knowledge score in the area, causes of tobacco use which had mean and SD 2.160.934 and equal percentage in the area of benefits of giving up tobacco which had mean and SD 1.62 0.878. Whereas least mean percentage was found in the area of concept of tobacco 20.5% which had mean and SD 0.82 0.850. The mean

percentage of in the area of types and forms of tobacco use was 47.33% which had mean and SD 1.42 0.642. The mean percentage in the ill-effects of tobacco use (physical) was 48% which had mean and SD 3.36 1.675. The mean percentage in the psychological aspects of ill-effects of tobacco use was 52.857% which had mean and SD 3.70 1.446 whereas in the area of steps in giving up tobacco the mean percentage was found to be 44% with the mean and SD 1.76 0.916.

58

Section C: Item-wise analysis of knowledge scores of the students


Table 3: Distribution of percentage of correct responses of students on ill-effects of tobacco use Sl. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Correct responses Item

No. % 22 6

Tobacco contains nicotine 42 Tobacco is addictive 12 Tobacco smoke releases harmful chemicals which 9 18 covers the lung surface The4 8 when tobacco use usually begins is around age 10years Tobacco use in adolescence is influenced by peer 23 46 group Tobacco use is more common among poor & 14 28 illiterate people Children of tobacco users rarely follow their 30 60 parents in their habits Smoking variety and smokeless variety are two 22 44 types of tobacco use Zarda, 50 25 gutkha and snuff are the examples of smoking variety Tobacco can be taken in many ways as chewing, 24 48 smoking, orally, nasally, behind the lip and along the gum Bad30 60 red eyes, headache, giddiness are the breath, delayed effects of tobacco use Tobacco smoke enters lungs by inhalation through 19 38 nose Chewing tobacco can lead to oral cancer and lung 18 36 cancer Children of smokers can develop asthma 42 Non-smokers who inhale the smoke cannot 50

11. 12. 13. 14. 15.

21 25

59

experience breathing difficulty 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. One13 26 cigarette/beedi reduces seven minutes of your life Babies 40 to tobacco user mother suffer from 20 born coughing and wheezing Excessive smoking during pregnancy can cause 9 18 abortion Smoking can cause tuberculosis 32 Tobacco use can lead to anxiety and depression 36 Tobacco users have good decision making capacity 60 Tobacco use improves sleeping pattern 44 Tobacco use improves concentration and memory 48 Tobacco use has a relaxing effect on the brain 34 Chewing tobacco leads to decreased sense of smell 27 54 and taste Tobacco dependents refuse to stop tobacco even 24 48 after having serious physical illness It is46 to stop smoking suddenly easy Giving up smoking is good to self and others 36 Tobacco use adversely affects overall performance 19 38 of physical and mental activities Giving up tobacco use improves self-confidence 38 Bad25 50 from mouth will always be there even breath after quitting tobacco It is23 46 necessary to have will power and motivation to quit tobacco When a tobacco user plans to quit he should keep it 29 58 a secret Chewing gum, toffee and cardamom are 19 38 alternatives for tobacco use Simple34 17 exercises like walking can reduce the desire for smoking 19 23 18 16 18 30 22 24 17

60

Item-wise analysis of the correct responses regarding ill-effects of tobacco use revealed that 42% of the students had knowledge that Tobacco contains nicotine; 12% knew that Tobacco is addictive and 18% knew that the Tobacco smoke releases harmful chemicals which covers the lung surface; 8%of the students knew that the age when tobacco use usually begins is around 10years; 46.00 % of the students had knowledge that Tobacco use in adolescence is influenced by peer group; 28%remarked that tobacco use is more common among poor & illiterate people.

Children of tobacco users rarely follow their parents in their habits was remarked by 60% of the respondents. For the item Smoking variety and smokeless variety are two types of tobacco use, 44% of the students responded correctly. 50% of respondents knew that Zarda, gutkha and snuff are not the examples of smoking variety. 48% of the respondents knew that tobacco can be taken in many ways as chewing, smoking, orally, nasally, behind the lip and along the gum.60% of the respondents knew that Bad breath, red eyes, headache, giddiness are the delayed effects of tobacco use; 38.% of the respondents knew that tobacco smoke enters lungs by inhalation through nose; 36% of the students responded correctly that chewing tobacco can lead to oral cancer and lung cancer;42% of the respondents knew that Children of smokers can develop asthma; 50% of the respondents knew that Nonsmokers who inhale the smoke can experience breathing difficulty.

Item-wise analysis of correct responses regarding ill-effects of tobacco use reveals that 26% of students knew that One cigarette reduces 7 minutes of life; 36% students responded correctly to item no.20 60%students knew that the tobacco users have good decision making capacity . forty-four percent of students knew that tobacco

62 61

use impairs sleepingof effectiveness of PTP on Ill-effect of tobaccocorrect response Part III: Evaluation pattern. 48.00% of the respondents had given and testing tobacco use improves concentration and memory Thirty-four percent of the student Hypothesis gave correct response that tobacco use has a relaxing effect on the brain; 54% of the Section A: Quartiles of the that chewing tobaccoknowledge scores sense of smell and taste; respondents knew pre-test and post-test leads to decreased 48% of the respondents knew that Tobacco dependents refuse to stop tobacco even 100 after having serious physical illness and 46% students responded correctly to item Pre-test 90 no.27. Thirty-six percent of the students knew that Giving up smoking is good to self 80Post-test and others7038% of the respondents knew that Tobacco use adversely affects overall ; e 60 g performance of physical and mental activities; 38%of the respondents knew that Percenta 50 Giving up40 tobacco use improves self-confidence; 50% of the respondents gave Median = 14 Median = 26 30 correct response for the item that Bad breath from mouth will always be there even 20 after quitting tobacco; 46% of the respondents knew that It is necessary to have will 10 Q3 Q1 Q2 Q1 Q2 power and motivation to quit tobacco;58% responded correctly for the item that when 0 10 12 14 20 22 a tobacco user0plans to quit he should16 18a secret; 38% of24 respondents knew 32 keep it the 26 28 30 Scores that Chewing gum, toffee and cardamom are alternatives for tobacco use and 34% of the respondents knew that Simple exercises like walking can reduce the desire for smoking.

Q3

Figure 14: Less than Ogives of pre-test and post-test knowledge scores The cumulative frequency distribution of pre-test and post-test knowledge scores are shown in the ogive. The data presented in the ogives shows significant difference between the pre-test and post-test knowledge scores. The pre-test median score was 14 whereas post-test median score was 26 showing a difference of 12. The ogive plotted shows that the first quartile score of post-test is higher than third quartile score of pre-test. This indicates that there is significant increase in the knowledge of students regarding ill-effects of tobacco use.

63

Section B: Area-wise effectiveness of PTP Table 4: Area-wise effectiveness of PTP with mean, SD and mean percentage of pre-test and post-test knowledge scores of students

Effectiveness (y-x) Pre-test (x) Maxi. Area Possible Mean score Mean SD % % Concept of 0 tobacco Causes of 7.33 tobacco use Types and 4 forms of tobacco use Ill effects of 0 tobacco use (Physical) Ill effects of 63 tobacco use (psychological) Benefits of 0 giving up tobacco Steps in giving 0 up tobacco 04 04 03 0.820.850 2.160.934 1.420.642 20.5 54.00 47.33

Post-test (y) Mean SD 3.580.609 1.840.738 1.880.385 Mean % Mean SD Mean 69.0

89.50 2.760.241 61.33 0.320.196 62.67 0.460.257

15.3

07

3.361.675

48.00

7.200.571

90.00 3.841.104

42.0

07

3.701.446

52.857 5.001.629

71.42

1.30.183

18.5

03

1.620.878

54.00

3.400.571

85.00 1.780.307

31.0

04

1.760.916

44.00

3.340.848

83.50 1.580.068

39.5

Data from table 4 shows that effectiveness of PTP in the area of concept of tobacco with highest mean percentage of 69% and mean and SD 2.76 0.241 whereas effectiveness of PTP in the area of causes of tobacco use with mean percentage 7.33% and with mean and SD 0.32 0.196. The effectiveness of PTP in the area of Types and forms of tobacco use with mean percentage of 15.34% and with mean and SD

64

0.460.257. The effectiveness of PTP in the area of Ill effects of tobacco use (Physical) with mean percentage of 42% and mean and SD 3.84 1.104 whereas the effectiveness of PTP in the area of Ill effects of tobacco use (Psychological) with mean percentage of 18.563 and with mean and SD 1.3 0.183. The effectiveness of

PTP in the area of Benefits of giving up tobacco with the mean percentage of 31% and mean and SD 1.780.307 whereas the effectiveness of PTP in the area of Steps in giving up tobacco with mean percentage of 39.50% and mean SD 1.580.068. However the result revealed that the overall percentage of post-test knowledge was more compared to the percentage of the pre-test knowledge. Hence it is observed that the PTP was effective in enhancing the knowledge of students regarding illeffects of tobacco use.

65

Section C: Item-wise effectiveness of PTP among the students on ill-effects of tobacco use.

Table 5: Effectiveness of PTP based on item-wise correct responses of the students in pre test and post test with regard to ill-effect of tobacco use Pre-test Post-test Effectiveness Items No. % No. % No. % Tobacco contains nicotine 50 Tobacco is addictive 80 Tobacco smoke releases harmful 9 18 45 90 36 72 chemicals which covers the lung surface The age8when tobacco use 4 41 82 37 74 usually begins is around 10years Tobacco use in adolescence is 38 influenced by peer group Tobacco use is more common 52 among poor & illiterate people Children of tobacco users rarely 20 follow their parents in their habits Smoking variety and smokeless 36 variety are two types of tobacco use Zarda, gutkha and snuff are the 10 examples of smoking variety Tobacco can be taken in many 42 ways as chewing, smoking, orally, nasally, behind the lip and along the gum Bad breath, red eyes, headache, 10 giddiness are the delayed effects of tobacco use Tobacco smoke enters lungs by 52 inhalation through nose Chewing tobacco can lead to 58 23 46 42 84 19 14 28 40 80 26 30 60 40 20 10 22 6 44 12 47 46 94 92 25 40

Sl. No. 1. 2. 3.

4. 5. 6. 7.

8.

22 44 40 80 18

9. 10.

25 50 30 60 5 24 48 45 90 21

11.

30 60 35 70 5

12. 13.

19 38 45 90 26 18 36 47 94 29

66

oral cancer and lung cancer 14. 15. Children of smokers can develop 48 asthma Non-smokers who inhale the 10 smoke cannot experience breathing difficulty One cigarette/beedi reduces 66 seven minutes of your life Babies born to tobacco user 52 mother suffer from coughing and wheezing Excessive smoking during 9 18 46 92 37 74 pregnancy can cause abortion Smoking can cause tuberculosis 62 Tobacco use can lead to anxiety 54 and depression Tobacco users have good 5 10 decision making capacity Tobacco use improves sleeping 12 pattern Tobacco use improves 8 concentration and memory Tobacco use has a relaxing 24 effect on the brain Chewing tobacco leads to 36 decreased sense of smell and taste Tobacco dependents refuse to 34 stop tobacco even after having serious physical illness It is easy to stop smoking 4 suddenly Giving up smoking is good to 60 self and others Tobacco use adversely affects 54 overall performance of physical and mental activities Giving up tobacco use improves 50 self-confidence Bad breath from mouth will 14 always be there even after 16 32 47 94 31 18 36 45 90 27 30 60 35 70.0 0 22 44 28 56 6 24 48 29 58 4 17 34 29 58 12 27 54 45 90 18 21 42 45 90 24 25 50 30 60 5

16. 17.

13 26 46 92 33 20 40 46 92 26

18. 19. 20. 21. 22. 23. 24. 25.

26.

24 48 41 82 17

27. 28. 29.

23 46 25 50 2 18 36 48 96 30 19 38 46 92 27

30. 31.

19 38 44 88 25 25 50 32 64 7

67

quitting tobacco 32. It is necessary to have will 36 power and motivation to quit tobacco When26tobacco user plans to a quit he should keep it a secret Chewing gum, toffee and 52 cardamom are alternatives for tobacco use Simple exercises like walking 44 can reduce the desire for smoking 23 46 41 82 18

33. 34.

29 58 42 84 13 19 38 45 90 26

35.

17 34 39 78 22

The findings reveal that highest percentage (80%) effectiveness was observed for the item Tobacco is addictive. Least percentage (4%) was observed for item number twenty-seven. Part IV: Testing of hypothesis To evaluate the effectiveness of planned teaching programme, a null hypothesis and alternative hypothesis was formulated. H0: There is no significant difference between the pre-test and post-test mean knowledge score of students regarding ill-effects of tobacco use. H1: The mean post-test knowledge scores of the students regarding ill-effects of tobacco use will be significantly higher than the mean pre test knowledge score. The hypothesis was tested using paired t test. The value of t was calculated to analyse the difference in knowledge of the students regarding ill-effects of tobacco use.

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Table 6: Significance of difference between pre-test and post-test knowledge scores Mean effectiveness 0.43691 t value 27.649 Table value 2.662 Level of

Areas significance Ill-effectsPof tobacco use < 0.005

Findings revealed that the mean post-test score was significantly higher than their mean pre-test score. The calculatedt value (t=27.649 p<0.005) was greater than the table value at 0.05 in all sections. Therefore, the null hypothesis was rejected and alternate research hypothesis was accepted indicating that the gain in knowledge was not by chance. Hence it is concluded that there is significant gain in knowledge of students through planned teaching programme on ill-effects of tobacco use. Summary This chapter dealt with the analysis and interpretation of the findings of the study. The data gathered were summarised in the master sheet and both descriptive and inferential statistics were used for analysis. Findings revealed that the mean pretest score was 14.0800 whereas the post-test mean knowledge score was 26.1600 Paired t test was used to analyse the effectiveness of PTP, which showed that the gain in knowledge was very highly significant (t=27.649, p<0.005).

69

Chapter 6 Discussion

69

DISCUSSION
The role of nursing professionals is crucial in giving health education and creating awareness among the community. The nurse must deliver health education in schools and colleges for the teachers and students. They must be helped to break the chain of embarrassment and develop awareness among themselves and give importance to their health. The present study was conducted to evaluate the effectiveness of PTP on illeffects of tobacco among adolescents with an aim to improve their knowledge regarding the ill-effects of tobacco use. The findings of the study are discussed under the following sections; Section I: Section II: Descriptions of the demographic characteristics of the students Analysis of the pre-test knowledge of the students regarding ill-effects of tobacco use. Section III: Evaluation of effectiveness of planned teaching programme on illeffects of tobacco use. Section IV: Testing hypothesis.

Section I Description of demographic variables of the students


Age wise distribution of study samples revealed that greater percentage (56%) of sample are in the age group between 12 -14years while 44% of respondents

70

belonged to the age group between 14-16 years. Percentage distribution of the parents according to the marital status shows that 96 % were living together and 4% of them were divorced. In relation to the distribution of students according to the gender showed that 60% of the students were male and 40.00% were female. Majority (62%) of the students had family history of smoking and tobacco use and only (38%) of the sample did not have family history of smoking or tobacco use. The analysed data regarding recreational facility of the students reveals that highest percentage (58%) of the students were using TV, 14% had DVD, 4% had radio, 8% had magazines, 2% had internet and only 14% were playing with peers Similar findings were found in another study conducted in Sikkim among1315years of students and the result revealed that Current smokeless tobacco users were likely to watch actors chewing tobacco on TV, video, or movies (90.4%); to watch gutkha brand names on TV sporting events or TV programmes (63.1% Vs 36.2%); to watch gutkha advertisement on hording at bus stops etc (63.8% Vs 33.9%); and gutkha advertisements in gutkha advertisements in the community events (65%Vs 38.7%)34 .

71

Analysis of pre-test knowledge score of the students regarding ill-effects of tobacco use
a. Assessment of level of existing knowledge Assessment of level of knowledge of the students shows that highest percentage (52%) of the students had average knowledge regarding ill-effects of tobacco use; and 48% of the students had poor knowledge regarding ill-effects of tobacco use. The findings of the study are consistent with the study conducted in India. The data indicated that highest consumption appeared to be in schools and colleges located in rural and semi-urban areas of Nagaland (63%) and Maharastra (13%). But the awareness level regarding the harmful effects of tobacco consumption were substantially low among children and youth.7 The findings of the study were inconsistent with a study conducted in Bhavanagar city, Jaipur. All students (100%) knew that smoking is injurious to health and cancer was caused by tobacco consumption.8 b. Analysis of the knowledge score of the students Comparison of area-wise mean and SD of the knowledge scores showed that in the area of ill-effects of tobacco use the pre test mean percentage of knowledge score was 40.22857% with mean SD of 14.08002.76892. The post test knowledge score was 74.74285% with mean SD of 26.16002.85971 showing the maximum increase of 34.51428% in the mean percentage knowledge score of the students with mean SD of 12.0800 3.08942.

72

The findings of the study are consistent with the study conducted at Jaipur, India that the greatest tobacco consumption was among illiterate and low education status people8. c. Item-wise analysis of knowledge score of the students Items related to ill-effects of tobacco use Item-wise analysis of the correct responses regarding ill-effects of tobacco use revealed that 42% of the students had knowledge that Tobacco contains nicotine; 12% knew that Tobacco is addictive and 18% knew that the Tobacco smoke releases harmful chemicals which covers the lung surface ; 8% of the students knew that the age when tobacco use usually begins is around 10years; 46% of the students had knowledge that Tobacco use in adolescence is influenced by peer group; 28% remarked that tobacco use is more common among poor and illiterate people.

Children of tobacco users rarely follow their parents in their habits was remarked by 60.00% of the respondents. For the item Smoking variety and smokeless variety are two types of tobacco use, 44% of the students responded correctly. 50.00% of respondents knew that Zarda, gutkha and snuff are not the examples of smoking variety. 48% of the respondents knew that tobacco can be taken in many ways as chewing, smoking, orally, nasally, behind the lip and along the gum.60% of the respondents knew that Bad breath, red eyes, headache, giddiness are the delayed effects of tobacco use; 38.% of the respondents knew that tobacco smoke enters lungs by inhalation through nose; 36% of the students responded correctly that chewing tobacco can lead to oral cancer and lung cancer;42% of the respondents

73

knew that Children of smokers can develop asthma; 50% of the respondents knew that Non-smokers who inhale the smoke can experience breathing difficulty.

The findings of the study are consistent with the study conducted in Bihar. That majority of the students were aware of the dangers of smoking (66%) and passive smoking (58%) and supported tobacco control (ban public smoking 72.2%).

The findings of the study was similar in Ballabgarh, Haryana. revealed that about 80% of the samples were aware of the adverse effects of smoking even then they were current smokers48 .

Section III Evaluation of the effectiveness of the planned teaching programme regarding ill-effects of tobacco use
a. Quartile distribution of pre-test and post-test knowledge scores of students regarding ill-effects of tobacco use The ogives plotted showed a significant difference between the quartiles of pre-test and post-test scores. The pre-test median score was 14and post-test median score was 26. The difference of 12indicates that there is an increase in the knowledge score.

74

c.

Item wise effectiveness of planned teaching programme Items related to ill-effects of tobacco use The findings reveal that highest percentage (80%) effectiveness was observed

for the item Tobacco is addictive. Least percentage (4%) was observed for item number twenty-seven. The findings are consistent with the study conducted in Ankara, Turkey which revealed that the education and training programme was successful in changing the knowledge and attitude regarding smoking among the school students51 .

Section IV Testing the hypothesis


Significant difference between pre-test and post-test knowledge score of the students regarding ill-effects of tobacco use Findings revealed that the mean post-test score was significantly higher than their mean pre-test score. The calculated t value (t=27.649 p<0.005) was greater than the table value at 0.005 in all sections. Therefore, the null hypothesis was rejected and alternate research hypothesis was accepted indicating that the gain in knowledge was not by chance. Hence it is concluded that there is very highly significant gain in knowledge of students through planned teaching programme on illeffects of tobacco use. The findings of the study was supported by a study whose result had shown that following planned teaching programme regarding the adverse effect of tobacco smoking on knowledge gain of 10
th

standard in a selected school of Kolar district in

75

Karnataka52 The study finding revealed a significant difference between pre-test and . post test knowledge scores (t value 19.18, p< 0.001) suggesting effectiveness of PTP in increasing the knowledge of students regarding the adverse effects of tobacco smoking.

76

Chapter 7 Conclusion

76

CONCLUSION
On the basis of the findings of the study, following conclusions are drawn: Distribution of level of knowledge of the students shows that highest percentage (52%) of the students had average knowledge regarding ill-effects of tobacco use; and 48% of the students had poor knowledge regarding ill-effects of tobacco use. Analysis revealed that out of 35 maximum obtainable scores the mean score was 14.0800 and the Standard Deviation was 2.76892. The mean percentage was 40.22857. Comparison of area-wise mean and SD of the knowledge scores showed that in the area of ill-effects of tobacco use the pre test mean percentage of knowledge score was 40.22857% with mean SD of 14.08002.76892. The post test knowledge score was 74.74285% with mean SD of 26.16002.85971 showing the maximum increase of 34.51428% in the mean percentage knowledge score of the students with mean SD of 12.0800 3.08942. However the result revealed that the overall percentage of post-test knowledge was more compared to the percentage of the pre-test knowledge. Hence it is observed that the PTP was effective in enhancing the knowledge of students regarding illeffects of tobacco use. The calculated t value (t=27.649 p<0.005) was greater than the table value at 0.005 in all sections.

77

Chapter 8 Summary

77

SUMMARY
The study was undertaken to evaluate the effectiveness of planned teaching programme regarding ill-effects of tobacco use among adolescents studying in a selected high school. The objectives of the study were to identify the pre-existing knowledge of adolescents regarding the ill-effects of tobacco using a structured questionnaire. design and administer a planned teaching programme on the ill-effects of tobacco. find the effectiveness of teaching programme using the same structured questionnaire. The study assumes that ill-effects of tobacco is common among children and it can be corrected by early guidance and counselling. Ill-effects of tobacco are very commonly seen in adolescents so there is a need to improve the knowledge regarding harmful effects and prevent the younger to leave the unhealthy practices and use their potentials in the right path so the nation can progress. The adolescent will have some knowledge regarding ill-effects of tobacco use and planned teaching programme will help in increasing the level of knowledge. The study examines the following hypothesis which was tested at 0.005 level of significance:

78

H1:

The mean post-test knowledge scores of adolescents regarding ill-effects of tobacco use was significantly higher than their mean pre-test knowledge scores. Independent variable was an intervention in terms of planned teaching

programme on ill-effects of tobacco use for the adolescent and dependant variable was change in knowledge. Extraneous variables are students age, family history of tobacco use and their sources of information from parents, friends, relatives, exposure to mass media, and from health personnel. The conceptual framework of the study was based on Panders Health promotion model. The model stresses on the influence of demographic variable on the cognitive perception of individual and importance of learners readiness or motivation in seeking health promoting behaviours. One group pre-test post-test pre-experimental design with an evaluative approach was adopted in order to achieve the objectives of the study. The sample of 50 high school students was selected by simple random sampling technique. The data was collected from them by using a closed ended structured knowledge questionnaire. The data obtained were analysed by using descriptive and inferential statistics. Findings are summarised as follows: Findings of the demographic variables revealed that, greater percentage (56%) of sample are in the age group between 12 -14years. In relation to the distribution of students according to the gender showed that 60% of the students were male and 40%

79

were female. Majority (62%) of the students had family history of smoking and tobacco use and only (38%) of the sample did not have family history of smoking or tobacco use. The analysed data regarding recreational facility of the students reveals that highest percentage (58%) of the students were using TV, 14% had DVD, 4% had radio, 8% had magazines, 2% had internet and only 14% were playing with peers Assessment of the level of the knowledge of the students regarding ill-effects of tobacco revealed that highest percentage (52%) of the students had average knowledge and 48% of the students had poor knowledge. Analysis shows that adolescents had highest mean percentage (54%) of the knowledge score in the area, causes of tobacco use which had mean and SD 2.160.934 and equal percentage in the area of benefits of giving up tobacco which had mean and SD 1.620.878. whereas least mean percentage was found in the area of concept of tobacco 20.5% which had mean and SD 0.82 0.850.The mean percentage of in the area of types and forms of tobacco use was 47.33% which had mean and SD 1.420.642. The mean percentage in the ill-effects of tobacco use (physical) was 48% which had mean and SD 3.36 1.675. The mean percentage in the psychological

aspects of ill-effects of tobacco use was 52.857% which had mean and SD 3.701.446 whereas in the area of steps in giving up tobacco the mean percentage was found to be 44% with the mean and SD 1.760.916. Data from table 4 shows that effectiveness of PTP in the area of concept of tobacco with highest mean percentage of 69% and mean and SD 2.76 0.241 whereas effectiveness of PTP in the area of causes of tobacco use with mean percentage 7.33% and with mean and SD 0.320.196. The effectiveness of PTP in the area of Types and

80

forms of tobacco use with mean percentage of 15.34% and with mean and SD 0.460.257. The effectiveness of PTP in the area of Ill effects of tobacco use (Physical) with mean percentage of 42% and mean and SD 3.84 1.104 whereas the effectiveness of PTP in the area of Ill effects of tobacco use (Psychological) with mean percentage of 18.563 and with mean and SD 1.3 0.183. The effectiveness of

PTP in the area of Benefits of giving up tobacco with the mean percentage of 31% and mean and SD 1.780.307 whereas the effectiveness of PTP in the area of Steps in giving up tobacco with mean percentage of 39.50% and mean SD 1.580.068. Quartiles of the knowledge scores of the pre-test and post-test showed a difference of 12 between pre-test median (14) and post-test median (26). This revealed an increase in knowledge level of adolescents after administration of PTP.

81

IMPLICATIONS
The present study emphasizes on effectiveness of planned teaching programme on ill effects of tobacco use among adolescents. The findings of the study may be provide useful information to health care providers teachers or peer counsellors if supervised properly to control the tobacco epidemic and to create awareness among the high school students. This study has a number of implications in the nursing practice nursing education, nursing administration and nursing research.

Implications for nursing practice


The school nurses can utilize the teaching programme to impart knowledge on ill-effects of tobacco use. The psychiatric nurses working among adolescents can also utilize the teaching programme in motivating them against tobacco use. In Science and continuing education programme can be organized for the purpose of prevention and also need to be planned implemented for the nurses working in hospitals and schools.

Nursing Education Nursing curriculum should lay more emphasis on the problems of ill effects of tobacco use. Nurse educators should have responsibility in upgrading the knowledge of students on ill effects of tobacco use, benefits of giving up tobacco use and steps to give it up. The curriculum committee can use the information obtained to integrate ill effects of tobacco use into the nursing education programme. The teaching programme can be utilized by the student nurses to organize awareness programme

82

regarding ill effects of tobacco use in schools as well as in the community among adolescents.

Nursing Research The study throws light on students knowledge regarding ill effects of tobacco use. There is a lot of scope for exploring this area. More and more research can be carried out on the students knowledge regarding ill effects of tobacco use in order to improve the health status of adolescents, to prevent accidents and premature death. Research can also be conducted to assess the learning needs of the high school students and the general public in order to increase the awareness regarding ill effects of tobacco use.

Nursing Administration In collaborators with education department nursing administrators should take the initiative in organizing in science and continuing education programme for the nurses regarding ill effects of tobacco use. This study also implies on the appropriate teaching - learning materials to be prepared and made available for nurses to create awareness regarding ill effects of tobacco use among the people.

83

LIMITATIONS
1. 2. Sample size was small so the generalization of the findings is limited. Study was conducted only in one high school so the generalization of the finding is limited. 3. The data collection tool used in the investigation were prepared for this purpose and used for the first time; the time constraint did not permit proper standardization of the tool.

RECOMMENDATIONS
The same study can be replicated on a larger sample. A similar study could be conducted with control group. A follow-up study can be conducted to determine the effect of teaching in terms of gain in knowledge and practice of ill effects of tobacco use. A similar study can be conducted by using other teaching strategies like SIM, health education materials, booklets, pamphlets etc. A comparative study can be conducted between rural and urban school students to assess their knowledge, attitude and practices regarding tobacco consumption. A similar study can be replicated in non-student youth. The present study can be conducted in college students.

Summary
This chapter dealt with summary of the study, conclusion and implication in nursing fields, limitation and recommendation.

77

Chapter 9 Bibliography

84

BIBLIOGRAPHY
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Sreevani R. Tobacco use during adolescence. Nurses of India 2005 May;7-11.

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Townsend M. Mental health nursing, Philadelphia,

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Gupta VM, Sen P. Tobacco: the addicted slow poison. Indian Journal of Public Health 2001 Jul-Sep;45:75-81.

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National Centre on Addiction and Substance Abuse (CASA). CASA white paper. No place to hide: Substance abuse in mid-sized cities and rural America. 2000;1-32.

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Annexures

92

Annexure 1
Letter seeking and granting permission to conduct the research study

93

Annexure 2
Letter seeking Permission to conduct the pilot study
From, The Block Education Officer, Balmatta Mangalore To, Prof. (Mrs.) B. V. Kathyayani Principal Dr. M. V. Shetty Institute of Health Sciences Mangalore Respected Madam, Subject : Grant of permission to conduct the research study I am glad to know that Mrs. Renu Shukla II Year M. Sc. Nursing student of your institution of eager to carry out a study on Effectiveness of planned teaching programme on the ill-effects of tobacco use among adolescents in a selected high school, Mangalore as a partial fulfillment of M.Sc. Nursing programme. I permit her to collect data from the participants and conduct the research study. I wish her all the best in her project work.

Thanking you, Yours truly,

94

Annexure 3
Letter granting permission to conduct the pilot study

95

Annexure 4 Letter seeking and granting permission to conduct the main study

96

Annexure 5
Letter seeking consent to validate the research tool and planned teaching programme
From, Renu Shukla II Year M. Sc. Nursing Dr. M. V. Shetty Institute of Health Sciences Mangalore 575 013. To, Forwarded through, Prof. (Mrs.) B. V. Kathyayani Principal Dr. M. V. Shetty Institute of Health Sciences Mangalore Respected Madam/Sir, Subject : Requisition for acceptance to validate the research tool and planned teaching programme I Mrs. Renu Shukla, II year M. Sc Nursing student of the above mentioned institution kindly request you to give consent to validate the tool and planned teaching programme on Topic: Effectiveness of planned teaching programme on the ill-effects of tobacco use among adolescents in a selected high school, Mangalore I would be highly obliged if you kindly give your acceptance. The acceptance form is enclosed herewith for your kind perusal. Thanking you, Yours sincerely, Renu Shukla Date: Place:

97

Annexure 6
Acceptance form for validation of tool and planned teaching programme

Name:

Designation:

Name of the College:

Statement of acceptance or non-acceptance I give my acceptance/non-acceptance to validate the tool Topic: Effectiveness of planned teaching programme on the ill-effects of tobacco use among adolescents in a selected high school, Mangalore.

Place: Date:

Signature of Expert

98

Annexure 7
Letter seeking expert guidance to validate the research tool and planned teaching programme

From, Renu Shukla II Year M. Sc. Nursing Dr. M. V. Shetty Institute of Health Sciences Mangalore 575 013. To,

Respected Madam/Sir, Subject: Requesting consent to validate the research tool and planned teaching programme. I, Renu Shukla, II year M. Sc. Nursing student of Dr. M. V. Shetty Institute of Health Sciences, have undertaken a research study on Effectiveness of planned teaching programme on the ill-effects of tobacco use among adolescents in a selected high school, Mangalore. I have prepared a structured knowledge questionnaire and PTP in this regard. Kingly validate the same for relevance, appropriateness and agreement of the content. Herewith I am enclosing: Blueprint and tool. Planned teaching programme.

99

Criteria checklist for the tool and PTP. I request you to kindly go through the content and give your expert and

valuable suggestions. Your expert opinion and kind cooperation will be highly appreciated and gratefully acknowledged. Thanking you,

Yours sincerely, Date: Place: Renu Shukla

100

Annexure 8 List of Validators

1.

Dr. Kiran Kumar Department of Psychiatry

2.

Prof. Irene Vagus Principal Sahyadri College of Nursing

3.

Prof. Chanu Bhattacharya HOD of Psychiatric Nursing Father Mullers College of Nursing

4.

Prof. Meera Pillai Principal Usha Nitte College of Nursing

5.

Mrs Reena George Lecturer of Psychiatric Nursing Yenapoya College of Nursing

6.

Prof Therasa Mathais HOD of Psychiatric Nursing SCS College of Nursing

7.

Mr. Nanda Kumar Lecturer Department of Psychiatric nursing MAHE, Manipal

101

8.

Prof. Leenu Sara George Department of Psychiatric Nursing MAHE, Manipal

9.

Mr. Shiva Kumar Department of Psychiatric Nursing Laxmi Memorial College of Nursing

102

Annexure 9

Cw v
w gt Pgg qwg qs AiAzg Ai AUj DAi dAUz U GAiUz zjuU U Pt PAiPz juPjv JA CzsAiz EZAz sUv. U F CzsAiz U At iwAi qVz AzsQU CUvg J iwAi qv. rz iwAi UVqUz v AzsAi GzP iv GAiVUz JAz U D qVz. g v g v 1. 26. 2. 27. 3. 28. 4. 29. 5. 30. 6. 31. 7. 32. 8. 33. 9. 34. 10. 35. 11. 36. 12. 37. 13. 38. 14. 39. 15. 40. 16. 41. 17. 42. 18. 43. 19. 44. 20. 45. 21. 46. 22. 47.

103

23. 48. 24. 49. 25. 50.

Annexure 10
Criteria checklist for validating the structured questionnaire Instructions Kindly review the items in the structured knowledge questionnaire for assessing the knowledge of adolescents regarding ill-effects of tobacco use. If you agree with the criteria, please place a ( 9 ) mark in the Agree column, otherwise, place a tick mark in the Disagree column.

Sl. No.

AgreeRemarks Disagree

Part I: Demographic proforma 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

104

Sl. No. 11.

AgreeRemarks Disagree

Part II: Structured knowledge questionnaire 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.

105

Sl. No. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35.

AgreeRemarks Disagree

106

Annexure 11 Evaluation criteria checklist for validity of planned teaching programme


Instructions: The evaluator is requested to go through the criteria listed below for the evaluation of the PTP on ill effects of tobacco use. The criteria checklist consists of 2 response columns Agree and Disagree and a Remarks column. Kindly place a tick mark ( 9 ) in the appropriate column and write your remarks in the Remarks column. Sl. DisNo. Criteria Agree agree Remarks 1. Objectives Formulation of objectives 1.1 General objective is comprehensive and contains all three domains as knowledge, application and understanding 1.2 Behavioural/specific objectives are stated in terms of learner outcome 2. 2.1 2.2 Content Selection of content is adequate Content is appropriate, accurate and adequate 3. 3.1 Organisation of content The content is organised in proper

107

Sl. DisNo. Criteria Agree agree Remarks sequence and logical fashion 4. Presentation Does the planned teaching programme contain 4.1 4.2 5. 5.1 An introduction Adequate content outline Language The language is easy to follow and understand by the participants 5.2 The terms are clarified properly by the researcher 5.3 The language is used grammatically sound 6. 6.1 Practicability The outline of planned teaching programme was interesting enough to make the participants attentive 6.2 The planned teaching programme is adequate to answer the questions 6.3 Provides enough knowledge to the participants to apply it in practice 7. 8. Acceptability Any other suggestions:

108

Sl. DisNo. Criteria Agree agree Remarks

Date:

Signature of the Validator

Annexure 12
Blueprint for knowledge questionnaire on ill-effects of tobacco use among adolescents

KnowKnowledgeTotal Percentage area ledge Concept of tobacco 11.42 Causes of tobacco 3 8.58 use Types and forms 8.58 of tobacco use Ill effects of 25.72 tobacco use (physical) Ill-effects of 22.86 tobacco use (psychological) Benefits of giving 11.42 up tobacco Steps in giving up 4 11.42 32-35 tobacco use Total 100.00 7 12, 18, 19 9, 10 1, 2

Comprehension Application 3 5-7 4 4

11, 13, 14, 17

15, 16

20, 21, 26

22-25, 27

29, 31

28, 30

14

14

35

109

20 40 40 100.00

Annexure 13
Tool for Assessment of Knowledge on ill-effects of tobacco use among adolescents Description of the tool
The tool to assess the data on the ill effects of tobacco use is divided into two parts as given below: Part I: Part II: Part I: Demographic proforma Instruction: Place a ( 9 ) mark against the appropriate option. 1. 2. Code No.: _____ Gender a. b. 3. Male [ ] Female [ ] This part contains 12 questions on the demographic profile of the subjects.

Age (in years) a. 12 14 [ ]

110

b. 4.

14 16

Type of family a. b. c. Nuclear [ ] Joint [ ] Extended [ ]

5.

Religion a. b. c. d. Hindu [ ] Muslim Christian Any other, specify ____________________ [] []

6.

Occupation of parents a. b. c. d. Service in private sector Service in government sector Business [ ] Agriculture [ ] [ [ ] ]

7.

Monthly income of the family (in rupees) a. b. c. d. 5,000 5,001 10,000 10,001 15,000 15,001 [ [ [ [ ] ] ] ]

8.

Marital status of the parents a. Living together [ ]

111

b. c. d. 9.

Divorced [ ] Separated Widowed [] [ ]

Status of living a. b. c. d. With parents With grandparents With relatives In the hostel [ [ [ [ ] ] ] ]

10.

History of smoking or tobacco use in the family? a. b. Yes [ ] No [ ]

11.

Previous knowledge regarding the ill-effects of tobacco? a. b. Yes [ ] No [ ]

12.

Recreational facility at home a. b. c. d. e. f. television DVD/VCD [ ] radio magazines and newspapers internet [ ] play with peers [ ] [] [ ] []

112

113

Part II: Knowledge regarding ill-effects of tobacco use Instruction: Read the following statements and state whether they are true or false by placing a 9 mark in the appropriate column.

True False Statements 1. 2. 3. Tobacco contains nicotine Tobacco is addictive Tobacco smoke releases harmful chemicals which covers the lung surface 4. The age when tobacco use usually begins is around 10 years 5. Tobacco use in adolescence is influenced by peer group 6. Tobacco use is more common among poor and illiterate people 7. Children of tobacco users rarely follow their parents in their habits 8. Smoking variety and smokeless variety are two types of tobacco use. 9. Zarda, gutkha and snuff are the examples of smoking variety 10. Tobacco can be taken in many ways as chewing, smoking, orally, nasally, behind the lip and along the gum. 11. Bad breath, red eyes, headache, giddiness are the delayed effects of tobacco use 12. Tobacco smoke enters lungs by inhalation

114

through nose True False Statements 13. Chewing tobacco can lead to oral cancer and lung cancer 14. Children of smokers can develop asthma 15. Non-smokers who inhale the smoke cannot experience breathing difficulty 16. One cigarette/beedi reduces seven minutes of your life 17. Babies born to tobacco user mother suffer from coughing and wheezing 18. Excessive smoking during pregnancy can cause abortion 19. Smoking can cause tuberculosis 20. Tobacco use can lead to anxiety and depression 21. Tobacco users have good decision making capacity 22. Tobacco use improves sleeping pattern 23. Tobacco use improves concentration and memory 24. Tobacco use has a relaxing effect on the brain 25. Chewing tobacco leads to decreased sense of smell and taste 26. Tobacco dependents refuse to stop tobacco even after having serious physical illness 27. It is easy to stop smoking suddenly 28. Giving up smoking is good to self and others

115

29. Tobacco use adversely affects overall performance of physical and mental activities True False Statements 30. Giving up tobacco use improves selfconfidence 31. Bad breath from mouth will always be there even after quitting tobacco 32. It is necessary to have will power and motivation to quit tobacco 33. When a tobacco user plans to quit he should keep it a secret 34. Chewing gum, toffee and cardamom are alternatives for tobacco use 35. Simple exercises like walking can reduce the desire for smoking

116

Answer key

1. 2. 3. 4. 5. 6. 7. 8. 9.

True 15. True 16. True 17. True 18. True 19. True 20. False 21. True 22. False 23.

False 29. True 30. True 31. True 32. True 33. True 34. False 35. False False

True True False True False True True

117

Annexure 14

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126 127

Annexure 15
Behavioural used Evaluation Objective Time Topic The group gets 2 min. Group introduced to Number of the topic participants present topic. Place Duration

Lesson plan on ill-effects of tobacco use


Content : IntroductionIll-effects of tobacco use : Adolescents (12-16 years) Adolescence, the age of experimentation and : 50 exploration, is known to be vulnerable to a variety of risk-taking behaviours such as selected high school : Classrooms of the substance abuse, : premarital sexual activity, and antisocial behaviours. 1 hour

Teaching activity

Learning AV aids activity

Introduces the The group Students are Blackboard topic motivated to listens learn the

Method of teaching : AdolescentsLecture-cum-discussion are influenced by the changes in the A. V. Aids used environment whichflash shape Blackpersonality either : Chart, can card, their board General objectives for the good or bad. Thus, a teenager with negative At the end of the teaching,personality may be pronedepth knowledge about the influence on his adolescents will have in for ill-effects of tobacco. behaviours such as substance abuse. Behavioural objectives substance-related disorders are composed of The At the end of the teaching programme thedisorders (dependence to: two groups the substance use adolescents will be able 1. 2. 3. 4. 5. 6. 7. 8. explain the concept of tobacco. enumerate the harmful chemicals present in tobacco. describe the causes of tobacco abuse. explain the characteristic features of a tobacco user. explain the types of tobacco use. list the forms of tobacco consumption. explain the ill-effects of tobacco. specify the benefits of giving up tobacco.

explain the steps of giving up tobacco use. 9.

128

Behavioural used Evaluation Objective Time

Content and abuse) and the substance induced disorders. Substance abuse is a psychoactive drug use of any class or type, used alone or in combination that poses significant hazard to health. The WHO identifies substance abuse as a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to use of substance. The substances include alcohol, caffeine and

Teaching activity

Learning AV aids activity

nicotine (tobacco), which have negative effect on health. One of the greatest causes of concern among adolescents is tobacco addiction. Since 1988, 31stMay has been observed as the World

129

Behavioural used Evaluation Objective Time

Content No Tobacco Day to reduce individual tobacco

Teaching activity

Learning AV aids activity

dependence. Explain the concept of tobacco 5Min Concept of tobacco Explains Listen and Blackboardis What answer

tobacco? Tobacco is addictive. The word tobacco is derived from the Spanish word tobaca. It contains nicotine, a chemical that is addictive making it very hard to quit or stop. It acts as a stimulant in small doses, but in larger amounts, it acts as a depressant. Most tobacco users start using tobacco before the age of 18 years, while some start as young as 10 years. According to WHO and Centre for Disease Control and Prevention tobacco use is the leading cause of death,

130

Behavioural used Evaluation Objective Time

Content globally causing 5 million deaths a year and it is the cause of 90% of lung cancer cases. By 2020, there could be an estimated 10 million deaths due to tobacco use among people under 15 years of age throughout the

Teaching activity

Learning AV aids activity

world. Enumerate the harmful chemicals present in tobacco 2Min Harmful chemicals in tobacco Tobacco contains more than 4000 chemicals. Nicotine, the active alkaloid of tobacco, is the principal addictive drug found in tobacco smoke. Other chemicals include tar, carbon monoxide, ammonia, nitrogen oxides, arsenic, hydrogen, cyanide, phenol, naphthalene, cadmium, urethane, acetone, butane and How many Explains and Listen and What are the asks questions harmful answer chemicals present in tobacco?

131

Behavioural used Evaluation Objective Time

Content radioactive compounds. Nicotine is absorbed through skin and mucosal lining of the mouth and nose, when chewed and by inhalation in the lungs if it is smoked.

Teaching activity

Learning AV aids activity harmful

chemicals are found in

tobacco?

Harmful chemicals when released from the tobacco cover our lung surface and thus cause respiratory problems. Describe the causes of tobacco abuse 5 mins. Causes of tobacco abuse Socio-cultural factors: Glamour created by heroes in tobacco abuse? movies, culture or peer pressure, especially during adolescence, appears to continue to tobacco abuse. Some reasons adolescents give for using tobacco are acceptance, rebellion, curiosity and relieving boredom. Explains theWhat are the The group causes of listens causes of tobacco abuse

132

Behavioural used Evaluation Objective Time

Content Socioeconomic class: The economically deprived and highly stressed people are more likely to use tobacco; so also are people living in unstable environments. Personality: People with antisocial behaviour and those with greater anger are likely to be tobacco users. Role model: Shown by a smoking father or a tobacco chewing mother has been observed as the reason for

Teaching activity

Learning AV aids activity

starting tobacco use. Explain the characteristic features of a tobacco user 3Min Characteristic features of a tobacco user A tobacco user presents with: i. Anxiety, guilt or shame. tobacco user Explains the Chart Listens List the characteristic characteristic and features of a features of a answers tobacco user

133

Behavioural used Evaluation Objective Time

Content ii. Anger when opposed to substance use. iii. Secretive use of tobacco. iv. Tobacco dependent uses at least one-and-a-half pack of cigarettes a day for at least one month. v. Continued use of tobacco even after having

Teaching activity

Learning AV aids activity

physical illness. Explain the types of tobacco i. 10Min Types of tobacco use There are two types of tobacco: tobacco? Smoking variety it includes cigarette, beedi, cigar, pipe, chillum, water pipe (hookah). ii. Smokeless variety examples are: Explains Listen and the What are types of answer questions

134

Behavioural used Evaluation Objective Time

Content Zarda tobacco leaf is boiled with spices and lime and then dried and coloured. Gutka It is a sweetened mixture of tobacco, betel and catechu, which is chewed together. Mishri this is powdered tobacco, which is dark roasted. Snuff snuff is finely powdered plant material. Snuff is either used plain or mixed with other agents. It may be used orally or nasally. In India, it is used as tooth cleaning agent. Pattiwala tobacco it is a sun-cured tobacco

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leaf. It may be used with or without lime.

135

Behavioural used Evaluation Objective Time

Content

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Learning AV aids activity

Smokeless variety or chewed tobacco is more likely to cause mouth cancer than smoking tobacco as tobacco is in concentrated form and kept in the mouth for a longer time. List the forms of tobacco consumption 5 mins. Forms of tobacco consumption There are various forms as to how tobacco can be consumed. consumption? a. Tobacco can be used as a thick paste. b. Granules or pills. c. As a tooth cleansing agent. d. Kept along the gum behind the lip. Lists the of tobacco consumption What are and Listen the tobacco

various formsanswer of forms

136

Behavioural used Evaluation Objective Time Can be used orally. e. f. Nasally. g. Under the tongue. Explain the illeffects of tobacco 10Min Ill-effects of tobacco

Content

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Learning AV aids activity

Listen Explains the Flash card What are the various effects short-term and of tobacco long-term

Physical effects These can be short-term or longterm. Short-term effects include: Bad breath. Red eyes. Headache. Giddiness. humans?

consumption? effects of tobacco on

137

Behavioural used Evaluation Objective Time Coughing. Long-term effects

Content

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Learning AV aids activity

Cancer cancer of lips, tongue, mouth, lungs, stomach and liver. Respiratory bronchitis, asthma. Reproductive decreased sperm count. Heart heart attack and high blood pressure. Eyes blindness due to Vitamin B12 deficiency. Nose sense of smell is reduced. Ear deafness. Anaemia

138

Behavioural used Evaluation Objective Time

Content Inflammation of the gums Peptic ulcer disease Delayed wound healing Voice rough and heavy voice. Reduced life span one cigarette/beedi reduces seven minutes of life. Aesthetic effect Tooth stains brown or black stains.

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Facial wrinkles, especially around mouth and eyes. Psychological effects Feeling of worthlessness

139

Behavioural used Evaluation Objective Time

Content Poor performance in studies Difficulty in concentrating Sleep and eating disturbances. Anxiety, depression, dementia. Impaired concentration and memory.

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Mental confusion. Explain the benefits of giving up tobacco 8 mins.

Benefits of giving up tobacco i. ii. The body starts repairing itself within 24 hours. One will get free from most of the nicotine within 7-10 days. iii. Appetite and taste improves. iv. Disappearance of bad breath and odour of smoke from clothes. Explains theWhat are and Listen the Chart benefits of giving up benefits of answer the giving up questions

smoking smoking?

140

Behavioural used Evaluation Objective Time v. Relief from cough.

Content

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vi. Family and co-workers protected from passive smoking. vii. The self-confidence and self-image of the person improves. viii. No more looks of disapproval or feelings of guilt. Explains how to quit or stop tobacco use. How to give up Throw away all of your tobacco. tobacco use? Clean your room if you have smoked there or left the tobacco packet lying. Throw away the ashtrays, lighters, empty packets, anything that you connect Explains Listen are the What steps to quit

141

Behavioural used Evaluation Objective Time

Content with your tobacco habit. Tell your friends that you are quitting tobacco. Ask them not to pressure you. Find other things to

Teaching activity

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do with them beside using tobacco. Decide on the date when you want to stop using tobacco. Plan little rewards for yourself for each tobaccofree day as going to movie with a friend or purchasing new clothes for you. Things to do instead of smoking or chewing chewing sugarless gums, toffee, cardamom, etc. Go to the place where you cant smoke. Remind yourself why you want to quit. Develop a healthy lifestyle skills. Exercise for five minutes or simple walk can reduce the desire for tobacco use.

142

Behavioural used Evaluation Objective Time Listen Blackboard Summarises the topic 3 mins.

Content Summary: During this session we have discussed about meaning of tobacco, prevalence, harmful chemicals of tobacco, causes and pattern of tobacco use, different forms of tobacco consumption, physical and psychological ill-effects of tobacco and also the benefits of giving up tobacco. 2 mins. Conclusion Adolescence, being a period of adventure and conflicts, is a vulnerable time when the youngsters fall prey to various misbehaviours including getting addicted to various substances such as tobacco. Tobacco use is the most widely prevalent problem among adolescents. It is necessary to create awareness among youngsters about the ill-effects of tobacco use.

Teaching activity Summarises the topic

Learning AV aids activity

144 143

Annexure 16
Behavioural vAQ zjuU used Evaluation Objective Time Content szU

P0i0id Bibliography

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Gupta VM, 0i Sen P. Tobacco the addictive slow poison. Indian Journal of Public Health. Jul-Sep 2001;45(3). 1. :ss vAP

0i zjuU 2. Bhatia MS. Essentials of psychiatry. New Delhi: CBS Publishers; 1992. . UA : qsg UA [12-16 rd
3. Townsend MC. Essentials of psychiatric mental health nursing. 3 ed.

U Varcarolis EM. Foundations of psychiatric mental health ed. W. B. nd nursing. 2Saunders Company. ] 4. sUg : 50 AS http://www.perio.org/consumer/smoking.htm. 5. : A P : MAz UAm 6. DSouza B. Nicotine addiction. My Doctor. July 2003. : G U ZZ 7. Srinivasan S. Workout your way out of cigarette addiction. My Doctor. May 2007. jw AP : PU izsU Becoming tobacco-free. Deccan Herald. May 31, 2007. 8. Chowdhary P. i 9. http://who.cdc/whr.asp zs0i szs0i CAvz zyU Rudman A. India inhales, 2000. Available from: URL:http://www.unaff.org/2001/f-india.html. 10. vAP 0i zjuU U wzPg . vz zs0iU sz0i CAvz qsg vAQ U Eg P ZgU jvg. vAQg C0iPj g0iPU niqvg. vAQ U PgtU jvg. vAP Q0i UtPtU jvg.

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175 176

TOTAL

AP PRE TEST PPgjP PART II 1234 1 5 7 8 izs zs0i 253647 8 9610 11 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 0i 112111211121 11 10001000010010001000110111000010000 ZlnPZln 1 00000011001000100001111110100010100 2 1 1 1 1 1 1 1 1 1 113 312111213226 12 00100100000000001011111000000011101 411111111111 11 00000010101000100000111100100010100 P 511111111111 16 00000010110111011110000011100011100
DEMOGRAPHIC DATA - PART I

MASTER zyU CHART

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611111111111 14 00000010110100110000111100100010011 711211111111 14 00000011011010101000111100100010100 811211213224 10 00000010101000100000011011000010100 911211312124 13 00001000101001011001000011011100100 10 1 1 2 1 2 2 1 2 1 2 3 19 10101011011011011100001011001101010 11 1 2 2 2 2 1 1 3 2 2 5 20 10100010111100111000010011111101011 12 1 2 2 1 1 1 1 1 2 2 3 18 10001011101011101110100101010001001 13 1 2 2 2 1 1 1 1 1 1 2 15 10010001000111000000011100011101011 14 1 1 1 1 1 2 1 1 1 1 6 15 11010001011100110011100000000001011 15 1 1 1 1 2 1 1 1 1 2 1 20 10001001111100110101110010110011101 16 1 1 1 1 1 2 1 2 2 2 4 15 11110000110000000010000000101111111 17 1 1 1 3 1 1 1 1 1 1 1 18 10000011011000000011111011001101111 18 1 2 2 1 1 1 1 1 1 2 1 12 10001001000110000000000110001110011 19 1 2 2 1 1 1 1 1 2 1 1 13 10001010010100101001000110010010001 20 1 2 2 1 1 2 1 1 2 2 6 15 00100110101100100010001101011001100 21 1 1 1 1 1 2 1 1 2 2 1 11 11000000100101000010100000101001100 22 1 1 1 1 1 1 1 1 1 1 1 18 01000010010111011011000011011101011 23 1 1 1 1 1 1 1 1 1 1 1 17 10001101010111000001000011011101011 24 1 1 1 1 1 1 1 1 1 1 1 13 00000010100111100000111100100010100 25 1 1 1 1 1 1 1 1 1 1 1 10 00000010101000100000110010100010100 26 1 1 1 1 1 1 1 1 2 1 1 11 10001000001001000010010000101001100 27 1 1 1 1 1 1 2 1 1 1 2 11 01001101001001100000001001000010010 28 1 1 1 3 1 1 1 1 1 1 1 11 00000010101001000000111100100010100 29 2 1 1 1 1 2 2 2 2 2 1 13 00000011101000100000111100110010100 30 2 1 1 1 1 1 1 1 1 1 1 11 00000010101000100000111100100010100 31 2 1 1 1 1 1 1 1 1 1 1 13 00001011001000100001111011000010100 32 2 1 1 1 1 1 1 1 1 1 1 14 00101010101000100000111100100011100 33 2 2 1 1 1 1 1 1 1 1 1 12 00001111010100100000100011000010100 34 2 1 1 1 1 1 1 1 1 1 1 14 00000010101000100000111011111100100 35 2 1 1 1 1 1 1 1 1 1 1 11 00001111001000010000100011000010100 36 2 1 1 1 1 1 1 1 1 1 1 17 00001110111000100001111111000011100 37 2 1 1 1 1 1 1 1 1 1 1 15 10001100111001001111100000100010100 38 2 1 1 1 1 1 1 1 1 1 6 18 10001011011011101111000011000100110 39 2 1 1 1 1 3 1 3 2 2 6 16 10001011010111011010000000100101011 40 2 1 1 1 1 3 1 3 2 2 4 17 10001101010101011011000011000101011 41 2 1 1 1 1 1 1 1 1 1 6 16 10000101010011001011000011011101010 42 2 1 1 1 1 3 1 3 2 2 2 15 10001110110000000001101001110100010 43 2 1 1 1 1 1 1 3 2 1 2 17 10001100101100001100101001011100011 44 2 1 1 1 1 3 1 3 2 1 2 16 00000010110011101000111100111100100 45 2 1 1 1 1 3 1 3 1 1 2 15 00000011010111011100000011011100100 46 2 1 1 1 1 2 1 1 2 2 1 11 00101001001000100001100001110000010 47 2 1 1 1 1 3 1 1 1 2 1 12 10010100101001000100100010000011010 48 2 2 2 1 1 3 1 1 2 1 6 10 01001000101010000000001010101000001 49 1 1 1 1 2 2 1 1 2 1 1 12 00100100000110010010101010010101000 50 1 1 1 1 3 3 1 1 2 2 2 13 00100011011010001001100010001001100 22 6 9 4 23 14 30 22 25 24 30 19 18 21 25 13 20 9 16 18 30 22 24 17 27 24 23 18 19 19 25 23 29 19 17

ZlnPUU CP dg 0iiUvg. vAP Zl FU qsg CPV PAqgvz. DzzjAz 0idg vAP 0i

zjuU U Cj

177

POST TEST PART II


TOTAL 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 20 111110000100111011110100010011101101 28 211111101011111011111100011011111111 29 311111101011111011111111011011101111 23 410111111010111101111111110111111111 28 511111101010111011111011111011101111 22 611101100111011011111000011011101001 30 711111101010111011111111111011111111 23 810111101011110010110111100011110110 29 911111101011111011111111111011110011 28 10 1 1 1 1 1 1 0 1 0 1 0 1 1 1 0 1 1 1 1 1 1 1 1 0 1 1 0 1 1 1 0 1 1 1 1 29 11 1 1 1 1 1 1 0 1 0 1 0 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 0 1 1 1 1 29 12 1 1 1 1 0 1 0 1 1 1 1 0 1 1 0 1 1 1 1 1 1 1 1 1 1 1 0 1 0 1 1 1 1 1 1 26 13 1 1 0 1 1 1 0 0 1 1 1 1 1 1 1 1 0 1 1 1 1 0 1 0 1 1 0 1 1 1 1 1 1 0 1 24 14 1 1 0 1 0 1 0 0 0 1 1 1 1 1 0 1 1 1 0 1 1 1 1 1 0 1 1 1 1 0 1 0 1 1 1 30 15 1 1 1 1 1 1 0 0 1 1 1 0 1 1 0 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 24 16 0 0 1 1 1 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 1 0 0 0 1 1 1 0 1 1 0 28 17 0 1 1 1 1 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 1 0 1 0 1 1 1 1 1 1 29 18 1 1 1 1 0 1 0 1 0 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 26 19 1 1 0 1 1 1 0 1 0 1 1 1 1 0 0 1 1 1 1 1 1 0 1 1 1 1 0 1 0 1 1 0 1 1 1 26 20 1 1 1 1 0 0 0 1 0 1 1 1 1 1 0 1 1 1 1 0 1 1 1 1 1 0 0 1 1 1 1 1 0 1 1 24 21 0 1 1 0 1 1 0 1 0 1 1 1 1 1 0 1 1 0 1 1 1 0 0 1 1 1 0 1 1 0 1 1 0 1 1 30 22 1 1 1 1 1 1 0 1 0 1 1 1 1 1 0 1 1 1 1 1 1 0 1 0 0 0 0 1 1 1 1 1 1 1 1 29 23 1 1 1 1 1 1 0 1 0 1 1 1 1 1 0 1 1 1 1 1 0 1 1 1 1 1 0 1 1 1 0 1 1 1 1 28 24 1 1 1 1 1 1 0 1 0 1 1 1 1 1 0 1 1 1 0 1 1 1 0 1 1 1 0 1 1 1 0 1 1 1 1 23 25 1 1 0 1 0 0 0 1 0 1 1 1 1 1 0 1 1 1 1 1 1 1 0 1 0 1 0 1 1 1 0 0 1 1 0 26 26 1 1 1 0 1 0 1 0 1 1 0 1 1 1 0 1 1 0 1 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 23 27 1 1 1 0 1 1 0 1 0 0 1 0 1 1 0 1 1 1 0 1 0 0 1 1 1 1 0 1 1 0 1 1 1 1 0 25 28 1 1 0 0 1 1 0 1 0 1 1 1 1 1 0 1 1 0 1 1 1 1 0 1 1 1 0 1 1 1 1 1 0 1 0 27 29 1 1 1 0 1 0 0 1 0 1 1 1 1 1 0 1 1 1 1 0 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 28 30 1 0 1 1 1 1 0 1 0 1 1 1 0 1 0 1 1 0 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 25 31 1 1 1 0 1 1 1 1 0 0 1 1 1 0 1 1 0 1 1 1 1 1 0 1 1 1 0 1 1 0 0 1 1 1 0 27 32 1 1 1 0 1 0 0 1 0 1 1 1 1 1 0 1 1 1 1 1 0 0 1 1 1 1 0 1 1 1 1 1 1 1 1 24 33 1 1 1 0 1 1 1 0 1 1 1 0 1 1 1 1 1 1 1 1 0 0 0 0 1 1 0 0 1 1 1 0 1 1 1 26 34 1 1 1 1 1 1 0 1 0 1 0 1 1 1 0 1 1 1 1 1 0 0 0 0 1 1 0 1 1 1 1 1 1 1 1 25 35 1 1 1 1 1 1 0 1 0 1 0 1 1 1 0 1 1 1 1 1 0 0 0 0 1 1 0 1 1 1 0 1 1 1 1 26 36 1 1 1 1 1 1 0 1 0 1 0 1 1 1 0 1 1 1 1 1 0 0 0 0 1 1 0 1 1 1 1 1 1 1 1 25 37 1 1 1 1 1 1 0 1 0 1 1 1 1 1 0 1 1 1 1 1 0 0 0 0 1 1 0 1 1 1 0 1 1 1 0 24 38 1 1 1 1 1 1 0 1 0 1 0 1 1 1 0 1 1 1 1 1 0 0 0 0 1 1 0 1 1 1 0 1 1 1 0 25 39 1 1 1 1 1 1 0 1 0 1 0 1 1 1 1 1 1 1 1 1 0 0 0 0 1 1 0 1 1 1 0 1 1 1 0 25 40 1 1 1 1 1 0 1 1 0 1 0 1 1 1 0 1 1 1 1 1 0 0 0 0 1 1 0 1 1 1 0 1 1 1 1 25 41 1 1 1 1 1 0 1 1 0 1 0 1 1 1 0 1 1 1 1 1 0 0 0 0 1 1 0 1 1 1 1 1 0 1 1 24 42 1 1 1 1 1 0 1 1 0 1 0 1 1 1 0 1 1 1 1 1 0 0 0 0 1 1 0 1 1 1 0 1 0 1 1 24 43 1 1 1 1 1 1 0 1 0 1 0 1 1 1 0 1 1 1 1 1 0 0 0 0 1 1 0 1 1 1 0 1 0 1 1 29 44 1 1 1 1 1 1 0 0 0 1 0 1 1 1 0 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 29 45 1 1 1 1 1 1 1 1 0 0 0 1 1 1 0 1 1 1 1 1 1 1 1 1 0 0 1 1 1 1 0 1 1 1 1 21 46 1 1 1 1 0 1 0 1 0 1 0 1 1 1 0 1 1 1 1 1 0 0 0 0 1 1 0 1 1 0 1 0 1 0 0 29 47 1 1 1 1 1 1 0 1 0 1 0 1 1 1 0 1 1 1 1 1 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 19 48 1 1 1 1 0 0 0 1 0 1 0 1 1 1 0 1 1 1 1 1 0 0 0 0 1 1 0 1 0 0 1 0 1 0 0 31 49 1 1 1 1 1 1 1 1 0 1 0 1 1 1 0 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 31 50 1 1 1 1 1 1 1 1 0 1 0 1 1 1 0 1 1 1 1 1 0 1 1 1 1 1 0 1 1 1 1 1 1 1 1 47 46 45 41 42 40 10 40 9 45 24 45 44 45 6 46 46 46 47 45 29 28 29 29 45 41 5 48 46 44 32 41 42 45 39

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