Web Prevention Intervention ACCEPTABILITY AND APPEAL OF A WEB- BASED SMOKING PREVENTION INTERVENTION FOR ADOLESCENTS By Amy E. Parlove Presented to the Health Education Faculty at the University of Michigan-Flint in partial fulfillment of the requirements for the Master of Science in Health Education First Reader Second Reader Web Prevention Intervention 2 ABSTRACT Cigarette smoking has been identified as the most important source of preventable morbidity and premature mortality worldwide (American Lung Association, 2002). Statistics show that youth who do smoke report having their first cigarette while in middle school (Eissenburg & Balster, 2000). This project helps expand current knowledge of adolescent smoking prevention programs by demonstrating an understanding of the preference of adolescents (acceptability of web as medium) and the presentation (appealing design elements). A qualitative usability study was conducted using focus groups. Results found that the Internet is a good choice for delivery of a prevention program due to its accessibility, including the availability in most schools. By using this non-traditional approach, health education and promotion needs to work in parallel with the following: school, parent and/or guardian, and community. This will assist in the future direction of health education programs delivered via the Internet. Web Prevention Intervention TABLE OF CONTENTS Chapter I: Introduction.............................5 Purpose........................................ 8 Research Questions.............................9 Significance................................... 9 Definitions................................... 10 University of Michigan Health Media Research Laboratory...........................11 Chapter II: Review of Literature.................. 12 Epidemiology..................................12 School-based Smoking Prevention Programs 14 Internet Use..................................20 Web Prevention Interventions................. 23 Web-based Smoking Interventions.............. 26 Focus Groups..................................30 Behavior Change Theory....................... 31 Chapter III: Methodology...........................41 Sub j ects...................................... 41 Variables.....................................41 Design........................................ 42 Procedures....................................42 Protocol...................................... 45 Analysis..................................... 4 9 Chapter IV: Results................................51 Focus Group Narrative Report................. 51 Focus Group Feedback Survey Results.......... 62 Chapter V: Discussion..............................66 Conclusions...................................66 Recommendations..............................7 0 References......................................... 73 Appendices 92 Web Prevention Intervention ACKNOWLEDGMENTS I wish to express sincere appreciation to Dr. Joan Cowder and Ms. Sarah Hoerauf for their commitment and assistance in the preparation of this thesis. In addition, special thanks to my family who were understanding and supportive Web Prevention Intervention 5 C h a p t e r I Introduction According to the Centers for Disease Control (2000), approximately 80% of adult smokers started smoking before the age of 18 and every day, nearly 3,000 young people under the age of 18 become regular smokers. The American Lung Association (2000) reports that approximately one- third of these youth or adolescent smokers will eventually die of a smoking-related illness. While Michigan has seen a significant reduction in smoking among 9-12 graders from 38.2% (Michigan State Board of Education, 1998) to 27.6% (Michigan Department of Community Health, 2002), these rates remain high. Statistics show that youth who do smoke report having their first cigarette while in middle school (Eissenburg & Balster, 2000). Almost 80% of adult smokers had their first cigarette by age 14 and developed a daily smoking habit by age 18 (Eissenburg & Balster, 2000). This demonstrates Web Prevention Intervention 6 then, that the key opportunities for prevention of this health risk is in childhood and adolescence. School-based programs can have a significant impact on smoking behavior among young people and are most effective when part of a comprehensive, community-based effort (Satcher, 2000). Implementing effective school-based programs, along with community and media-based activities, can prevent or postpone smoking onset in 20 to 40 percent of U.S. adolescents (Satcher, 2000). In conjunction with over 25 national, federal, and voluntary agencies, the Centers for Disease Control (CDC) has developed the Guidelines for School Health Programs to Prevent Tobacco Use and Addiction. Of the key principles outlined, it states that the curriculum should be introduced in elementary school and then intensified in middle/junior high school, which is when students are exposed to older students who use tobacco at higher rates (National Center for Chronic Disease Prevention and Health Promotion, 1997). Unfortunately, less than 5 percent of schools nationwide have implemented the major components of the CDC's recommended guidelines for school-based programs Web Prevention Intervention 7 to prevent tobacco use (Satcher, 2000). There are a number of teen smoking prevention interventions, but even effective interventions will have limited impact unless the intervention is readily available and is easy to implement in a target population (Pallonen, 2001). Using computers and the Internet for a smoking prevention intervention allows users the ability to access the program at any time. More than 25 million kids ages 2- 17 are online in America and millions more will be coming online from both home and school (Grunwald Associates, 2000). Teenagers report that they are more likely to be on the Internet at school than at home (Grunwald Associates, 2000). By the fall of 2000, 98% of public schools were connected to the Internet as compared to 35% in 1994 (Williams, 2000). Over half of public schools with access to the Internet reported that computers with access to the Internet were available to students outside of regular school hours (Williams, 2000) . What will adolescents use in order to seek information and/or help on smoking issues and why would they use it? Web Prevention Intervention 8 Purpose This thesis project will focus on two unique areas of smoking prevention for adolescents. The first intent of the project is to determine the acceptability of the web as a delivery medium {as compared to other mediums) for a smoking prevention intervention. The second intent is to identify design elements for inclusion in a web-based smoking prevention intervention that are appealing to adolescents. This project will inform a larger web-based program designed to teach adolescents how they can remain non-smokers and/or how they can acquire skills that support smoking cessation. This project will help expand current knowledge of adolescent smoking prevention programs by gaining a better understanding of the preference of adolescents (acceptability of medium) and the presentation (appeal). The potential success of web-based prevention interventions relies on the abilities of health educators to create new and innovative tools. This approach contributes to the health educator's abilities to develop such tools by putting the creativity of learning in the hands of the Web Prevention Intervention target audience, resulting in a program designed FOR adolescents BY adolescents. Research Questions 1. Do adolescents find the delivery medium (Internet in a classroom setting) of the smoking prevention intervention preferable as compared to other types of intervention media? 2. What design elements should be included in a web-based smoking prevention intervention to make it appealing to adolescents? Significance An intervention that is web-based is practical for multiple reasons, it: reaches a wide audience, is inexpensive to implement, is easy to update and collect data, and is easily accessible. To date, there are a limited number of web-based health education programs that have been evaluated, and even less research has been done with adolescents to evaluate the acceptability and appeal of such programs. This thesis will contribute to filling Web Prevention Intervention 10 this void, and will demonstrate the potential for future use of this type of intervention. In summary, the three points of significance that support this project are as follows: 1. Teen smoking is a problem. 2. Schools are a logical location for prevention programs. 3. The Internet is a good choice for delivery of a prevention program due to its accessibility, including the availability in most schools. By answering the questions of "adolescent preference and appeal", the focus of this project will assist in the future direction of health education programs available on the Internet. Definitions Delivexry medium — video, print materials, Internet, classroom teacher, word of mouth Web design elements — graphics, sound (voiceovers), interactive games, surveys, personal!zation ASHES — Anti-Smoking Health Education Sources; Web-based