Developing a Theory-based Health Education Intervention to Prevent Adolescent Students from Smokeless Tobacco Consumption

Developing a Theory-based Health Education Intervention to Prevent Adolescent Students from Smokeless Tobacco Consumption | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Developing a Theory-based Health Education Intervention to Prevent Adolescent Students from Smokeless Tobacco Consumption Anil Kumar Mandal, Chitra Bahadur Budhathoki This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6891275/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Dec, 2025 Read the published version in BMC Public Health → Version 1 posted 11 You are reading this latest preprint version Abstract Background Smokeless tobacco is a kind of tobacco that is chewed or sniffed; e.g., khaini , gutkha , paan-parag , and paan . It is harmful to health, but over 300 million people in the world consume it. Its consumption among the adolescent students of Nepal is increasing. It needs to develop a theory-based health education intervention to prevent students from consuming smokeless tobacco. Method Four focus group discussions were conducted among the students of Class 9 by following the guidelines based on constructs of protection motivation theory. Based on the rigorous review of literature and feedback from the supervisor, a module of theory-based health education intervention was drafted. After that, a pilot test of the intervention was conducted among the students of Class 9. Data from 16 students who participated in the pilot test was analyzed to identify reliability and face validity of the intervention. The content validity of the intervention was assured through feedback from the supervisor and literature. After that, the final draft of the theory-based health education intervention was prepared. Results We found students who participated in focus group discussions had insufficient knowledge regarding smokeless tobacco and its harmful effects. They had many misconceptions related to smokeless tobacco consumption. They accepted the need for skills to prevent themselves from smokeless tobacco consumption. They voiced that the strict rules should be implemented in the school premises to control tobacco consumption. Including the information related to these findings, the protection motivation theory-based health education intervention was developed. Cronbach’s alpha values of each objective of each session were more than .8. More than 80% of participants of the pilot test agreed with the effectiveness and appropriateness of the components of the intervention. Conclusion We developed a highly reliable and valid protection motivation theory-based health education intervention. Its proper implementation might raise knowledge of students regarding smokeless tobacco and its effects and enhance their skills to prevent its consumption. Adolescent Behavior Health education intervention Protection motivation theory School smokeless tobacco Students Background Smokeless tobacco (SLT) is a kind of tobacco that is consumed through the mouth or nose without candling it [ 1 ] and is also known as spitting tobacco [ 2 ]. Khaini / surti , Gutkha , Zarda , Paan containing tobacco constituents ( betel quid ) [ 2 , 3 ], tobacco leaf , kiwam [ 2 ], snuff , and gul [ 3 ] are different types of SLT. It contains approximately four thousand toxic, mutagenic, and carcinogenic chemicals along with highly addictive Nicotine [ 4 ]. Cancer of the mouth and pharynx [ 5 ], heart diseases [ 6 ], and inflammation of gingiva, decaying of teeth, oral submucous fibrosis, and development of leukoplakia [ 7 ] are attributed to consumption of SLT. SLT consumption is detrimental to health, but over 300 million people in the world are consuming SLT [ 8 ] and attracting more adolescents towards it [ 9 ]. Although it has created a compound and pervasive challenge to health and economy, especially in low- and middle-income countries (LMICs) [ 10 ], the researchers and policymakers are not seen focusing on it, and still the international efforts of tobacco control are mostly centered on cigarettes rather than other forms of tobacco [ 8 – 11 ]. They neglect it because SLT is considered less harmful than smoking and is a regional problem that is more complicated to control [ 8 ]. Similarly, dodging the laws against tobacco and advertising SLT as the alternative to cigarette smoking to maintain nicotine levels by manufacturer companies of SLT are helpful for smoking cessation programs, but it ultimately increases the consumption rate of SLT [ 9 ]. Adolescents are considered as more vulnerable to risk-taking behavior [ 12 ], and consumption of tobacco is a door for drugs such as marijuana and cocaine [ 13 , 14 ] and alcohol. And consumption of SLT is increasing among youths of Nepal compared to youths of other East Asian countries [ 15 ]. All these facts indicate that adolescents should be awakened and equipped with knowledge and skills against SLT consumption. Besides it, only a few researchers have followed PMT [ 16 ]; this study aimed to develop PMT-based health education intervention to prevent adolescent students from consuming SLT. Methods Study Design Developing a draft of a module of an intervention, identifying its validity and reliability, and finalizing the draft are the stages of developing a module [ 17 ]. A needs assessment, drafting the module of intervention, conducting a pilot test of intervention to assure its reliability and validity, and finalizing the module of the intervention were the procedures of development of health education intervention (HEI). Besides it, rigorous literature review and regular feedback from the supervisor were the means of developing intervention. Protection Motivation Theory (PMT) Initially, in 1975, Rogers developed PMT by including variables of fear appeals to expectancy-value theory [ 18 , 19 ] and modified it in 1983 [ 20 ]. Perception of severity, perception of vulnerability, perception of intrinsic rewards, perception of extrinsic rewards, perception of response efficacy, perception of self-efficacy, and perception of response cost are the constructs of modified PMT. The higher perception of severity, vulnerability, response efficacy, and self-efficacy and the lower perception of intrinsic and extrinsic rewards, and response cost raise the protection motivation that pushes to change the attitude and behavior of a person. Needs Assessment The needs assessment was conducted before drafting the module of the intervention. For this, we conducted four focus group discussions (FGD) among the students of Class 9 in a separate classroom to prevent disturbances like noise. We developed guidelines for FGDs (see Additional file 1) based on the constructs of PMT and followed them. In each FGD, 7–9 students participated. FGDs were conducted in both Nepali and Maithili languages till the point of saturation [ 21 ], where little or no new opinions arise, and lasted from 50 minutes to one hour. A mobile, model Vivo 27, was used to audio record it. The audio records of FGDs were transcribed into the Nepali language. The transcripts were read many times to make sense. Themes were extracted from the transcripts of the FGDs by following the sequence of codes, categories, and themes, and then it was translated into the English language. Drafting of Intervention The module of the intervention was drafted based on the objectives, guided theory, target group and their needs, and time allocated for the study [ 17 ] including insights from literature, feedback from the supervisor, insights gained from the pilot test and suggestions from student during informal talks. Pilot Test of Intervention A pilot test of the intervention, two sessions each week, was conducted among 20 to 25 students of Class 9. Each session took 45 minutes to complete, but the first and concluding sessions. The first session took 90 minutes. In this way, the pilot test was completed in 4 weeks, including one extra concluding session in the fourth week. Only data of 16 students (boys-7, girls-9), who were present in each session, was analyzed. Reliability of Intervention The questionnaire based on the objectives of the module is used for identifying its reliability (Jamaludin Ahmad and Sidek Mohd Noah, 2001) [as cited in 17]. We developed and used a self-reported questionnaire based on the objectives of each session—except the 10th session—to calculate Cronbach’s alpha to identify the reliability of the intervention (see Additional file 2). The questionnaire contained 72 items, three for each of the 24 objectives of 8 sessions. The questionnaire was a five-point Likert scale type, ranging from strongly disagree (1) to strongly agree (5). After 1 week of finishing the pilot test of the intervention, data was collected by administering questionnaires among the students. The guidance was facilitated by the researcher on any confusion or difficulties related to questions. After collection of data, it was edited and entered into Statistical Package for Social Science (SPSS) version 20 to calculate Cronbach’s alpha to assure the reliability of the module of the intervention. Validity of Intervention Through literature and experts [ 22 ], content validity was ensured. For this, regular feedback was received from the supervisor, and a rigorous literature review was performed. The participants of the pilot test, a subgroup of the study population [ 21 ], were the means for ensuring face validity of the contents of the intervention. We developed a self-reported five-point Likert-scale-type questionnaire ranging from strongly disagree (1) to strongly agree (5) along with the questionnaire for the reliability test of the intervention (see Additional file 2), and administered among the students to identify the face validity of the module of the intervention. It contained 7 items related to contents, activities, teaching materials, and time allocated for the sessions. But it was analyzed by categorizing it into disagree, neutral, and agree. Likewise, informal 3- to 5-minute talks with 3 students about the contents and activities of the modules of the intervention were done to assure the face validity of the module. Results The draft of the module of the protection motivation theory-based health education intervention was developed. Through FGDs, themes were derived in the line of constructs of PMT. Knowledge related to SLT, effects of SLT consumption (severity of SLT), hazards of SLT consumption (vulnerability of SLT), misconceptions related to rewards of SLT consumption (intrinsic and extrinsic rewards), preventive measures of SLT consumption (response efficacy), skills needed to prevent SLT consumption (self-efficacy), misconceptions related to the cost of not consuming SLT (response cost), and peer as the source of SLT consumption were the themes derived from FGDs. We found that many students had not sufficient knowledge regarding SLT. They considered tobacco, alcohol, and drugs as tobacco. They thought that smoked and smokeless tobacco were the same. They were not aware of the harmful chemicals found in SLT and its effects. They thought that almost all people consume tobacco, and more people who do not consume tobacco are suffering from cancer and dying than those who consume tobacco. Some of them also thought that not consuming SLT is good for health. They mentioned that consuming SLT is relaxing and prestigious among people. They accepted that peer pressure was a dominating factor of consuming SLT. They realized the need for life skills to prevent SLT consumption. They echoed the need for an awareness program and implementation of strict rules in school settings to prevent tobacco use. Drafting and Finalization of Intervention Before the pilot test, HEI had 9 sessions, including 1 concluding session. For each of the 7 constructs of PMT, one session of intervention was drafted, except for self-efficacy, which had 2 sessions. After the pilot test, we slightly modified HEI. The 1st session was divided into two sessions, the third and the fourth sessions were merged into one session, and the seventh session was divided into two sessions. It had 10 sessions without altering the contents and objectives, which it had before the pilot test, including a quiz contest and concluding session. Session 1st had focused on knowledge related to tobacco and SLT. Session 2nd was related to the severity of SLT consumption, session 3rd was related to the vulnerability of SLT, session 4th was related to the extrinsic and intrinsic rewards of SLT, session 5th was related to response cost, session 6th was related with response efficacy, and sessions 7th, 8th, and 9th were concerned with self-efficacy. In this way, contents related to each of the seven constructs of PMT had been included in the intervention. The 10th session was a quiz contest and concluding session, which was related to the contents of sessions 1 through 9 to solidify the knowledge and skills acquired by students in each session. Table 1 images the final number of sessions with contents and objectives of the intervention after the pilot test. Table 1 Sessions of the intervention with contents and objectives Sessions Contents Objectives 1. Introduction to Smokeless Tobacco - Introduction - Types of SLT - Chemical Found in SLT - Introduce smokeless tobacco - identify different types of SLT - list chemical found in SLT 2. Prevalence and Effects of SLT Consumption - Prevalence of SLT - Short term effects of SLT - Long term effects of SLT - Mortality Caused by Tobacco - explain proportion of people who consume smokeless tobacco - describe short terms effects of SLT - describe long terms effects of SLT - describe mortality caused by tobacco 3. Addiction and Hazards of SLT Consumption - Addiction of SLT - Probability of Hazards Caused by SLT Consumption - Positive Aspects of not Consuming SLT - explain the process of addiction due to SLT consumption - describe the probability of hazards caused by SLT consumption - list the positive aspects of not consuming SLT 4. Misconception Related to Rewards of SLT Consumption - Misconceptions Related to Intrinsic Rewards of SLT Consumption - Misconceptions Related to Intrinsic Rewards of SLT Consumption - identify misconceptions related to intrinsic rewards of SLT consumption - explain misconceptions related to extrinsic rewards of SLT consumption 5. Misconception Related to Cost Paid for not Consuming SLT - Misconceptions Related to Cost Paid for not Consuming SLT - Social/Group Norms - describe misconceptions related to cost paid for not consuming SLT - able to differentiate positive and negative group norms 6. Preventive Measures of SLT Consumption - Preventive Measures of SLT - explain preventive measures of SLT consumption - accept the importance of prescribed behaviors to prevent from SLT consumption 7. Decision Making - Introduction of Decision Making - Steps of Decision Making - describe decision making - list the steps of decision making - able to apply the steps of decision making in their behavior 8. Peer Pressure - Introduction of Peer Pressure - Ways of Coping Peer Pressure - describe peer pressure - explain the ways of coping peer pressure - able to apply the ways of coping peer pressure in behavior 9. Saying ‘NO’ SLT - Introduction of Saying ‘NO’ SLT - Different Ways of Saying ‘NO’ SLT - describe different ways of saying ‘NO’ SLT - able to apply the different ways of saying ‘NO’ in their behavior 10. Quiz Contest and Concluding - Quiz Related to above Sessions - to solidify the knowledge and skill achieved in the previous sessions Reliability of Intervention Cronbach alpha values of each objective of respective sessions were high and acceptable, ranging from .807 to .880. Cronbach alpha values for each objective are presented in Table 2 . Table 2 Objective wise Cronbach Alpha of each session Sessions No. of objectives for each session No. of questions for each objectives Value of Cronbach Alpha 1. Introduction to Smokeless Tobacco 1 3 .824 2 3 .826 3 3 .857 2. Prevalence and Effects of SLT Consumption 1 3 .880 2 3 .842 3 3 .815 4 3 .815 3. Addiction and Hazards of SLT Consumption 1 3 .824 2 3 .828 3 3 .864 4. Misconceptions Related to Rewards of SLT Consumption 1 3 .822 2 3 .865 5. Misconceptions Related to Cost Paid for not Consuming SLT 1 3 .867 2 3 .807 6. Preventive Measures of SLT Consumption 1 3 .827 2 3 .814 7. Decision Making 1 3 .817 2 3 .858 3 3 .818 8. Peer Pressure 1 3 .836 2 3 .821 3 3 .838 9. Saying ‘NO’ SLT 1 3 .846 2 3 .846 Validity of Intervention More than 80% of students agreed to the effectiveness and appropriateness of all components except the time allocated for each session. Less than 70% of students agreed to the time allocated for each session. During informal talks with students, they mainly suggested breaking down the first session into two sessions and merging the session third and the session fourth into one session. Agreement percentages by participants for each component of the sessions are presented in Table 3 . Table 3 Agreement percentages for each component of the sessions Components D (%) A (%) The contents were clear and understandable 12.5 87.5 The contents were useful to meet the needs of students 6.2 93.8 The contents meet the learning standard of students 12.5 87.5 The learning materials are clear and readable 12.5 87.5 The teaching-learning activities were appropriate to meet the needs of students 12.5 87.5 The teaching-learning activities created the opportunity for active learning 12.5 87.5 The time allocated for each session was appropriate 31.2 68.8 D: Disagree; A: Agree Discussion Inadequate knowledge regarding tobacco use might lead to undesired attitudes [ 23 ]. But, we found students had insufficient knowledge regarding tobacco, SLT, and its impact on health. Only a few of them were known to chemicals found in SLT, which are responsible for addiction and diseases like cancer. Besides it, they were misinformed about the probability of hazards of SLT consumption, misconceptions about rewards related to SLT consumption, and misconceptions related to cost paid on not consumption of SLT. Therefore, information related to it was included in the sessions of HEI. Including the contents related to different aspects of SLT in the intervention might have a positive impact on the SLT consumption behavior of students because knowledge about the harms of tobacco is one of the protective factors of its consumption [ 24 ]. Not only this, Wang et al. [ 25 ] reported that the school-based tobacco use prevention program ‘towards no tobacco use (TNT)’ was a more highly cost-effective intervention than other prevention programs. Similarly, Tahil et al. [ 26 ] found that school-based smoking intervention raises the knowledge related to ill impacts of smoking and enhances the negative attitude towards smoking among students. Likewise, Reed et al. [ 27 ] assessed a spit tobacco prevention curriculum conducted in West Virginia and found that the implementation of the curriculum had a positive impact on the knowledge of students regarding tobacco consumption. Therefore, we can say that providing knowledge about SLT might increase the level of knowledge of students. Having misconceptions regarding the rewards of SLT consumption and the cost paid for not consuming SLT are the significant factors of its consumption. Considering smoking as attractive and convenient at social activities are significant factors of smoking [ 28 ]. People consume tobacco as a stress reducer, and some people consume tobacco to maintain body weight [ 29 ] to look fit and smarter. However, a study [ 30 ] showed that very few students perceived tobacco consumption as a cool, comfortable enhancer and stress reducer; some people accept that tobacco consumers have more friends. Likewise, personal attitude towards tobacco and social norms are significant contributors to tobacco use [ 31 ]. In the FGDs, students voiced such misconceptions related to SLT consumption; therefore, information about such misconceptions was included in the intervention. Skills are necessary to practice on the knowledge achieved and attitude developed. Social cognitive theory [ 32 ] emphasizes the need and importance of self-efficacy to perform action. It accepts perception of self-efficacy as a vital component to have mastery over desired action or behavior. Maddux and Rogers [ 18 ] emphasized self-efficacy as one of the main constructs of PMT to achieve desired behavior. But the FGDs showed that participants had no sufficient skills related to decision-making, how to cope with peer pressure, and how to say ‘NO’ to proposals of SLT consumption from their peers. They felt hesitation regarding these skills that are necessary to keep themselves away from SLT consumption. All of them accepted the need for skills that prevent SLT consumption. Keeping it in mind, some life skills such as decision-making, coping with peer pressure, and saying ‘NO’ to SLT were included in the sessions of HEI. This intervention might have a positive impact on SLT consumption behavior of students because after assessing the spit tobacco prevention program conducted in West Virginia, Reed et al. [ 27 ] reported that the implementation of the curriculum had a positive impact on tobacco consumption behavior of students. They mentioned that almost all students were able to list the things to purchase instead of spit tobacco, to say no to their friends who offered spit tobacco to them, and to get more involved in the prevention of spit tobacco use in their school or community. Participants of FGDs accepted peers as the main source of SLT consumption. Therefore, contents related to peer pressure and how to refuse the proposal of a peer to consume SLT were included in the intervention. Many studies have shown the effectiveness of peer-oriented intervention. Because Lund et al. [ 33 ] had emphasized that prevention programs should focus on the role of peers and family to control it. Similarly, a peer-led, school-based tobacco control intervention has a significant effect on reducing SLT consumption [ 34 ]. Adolescence is a transitional period between the stages of childhood and adulthood of life, and they might be involved in risk behaviors [ 35 ], and they might be incapable of making the right decision. In this period, they need a guideline for the right decision. In the lack of capability of decision-making, they might be involved in risks such as SLT consumption. They might be engaged in destructive works rather than positive and creative works. The capability of decision-making skills is an asset of youths and a symbol of positive identity and social competencies that leads them to constructive and positive behavior [ 36 ]. Therefore, it is necessary to enhance their capacity of decision-making to prevent them from risk-taking behaviors like consumption of SLT. Researchers have no consistency regarding the value of Cronbach’s Alpha to set the standard of reliability of intervention. Good and acceptable values of Cronbach’s Alpha varied from .60 to .80 [ 22 ] and from .65 to .90 [ 17 ]. We found high and acceptable reliability for the intervention because no sessions had a Cronbach’s Alpha value less than 0.8. We obtained high face validity for the components of the sessions of the intervention. Almost all students agreed with the contents and learning activities included in the sessions of intervention. However, some (one-third) of the students disagreed with the time allocated for the session, especially the first session, which was modified. It needs an agreement percentage of 75 to be valid, and the agreement percentage below 75 needs to be revised [ 37 ]. In this regard, the first session was divided into two sessions, the third session and the fourth session were merged into one session, and three sessions were separated for self-efficacy to manage time. This study was not free from limitations. Needs assessment was limited to the constructs of PMT. In the intervention, we only included how to cope with peer pressure, how to make decisions, and how to say ‘NO’ SLT among the various life skills. It had limited sessions and time duration. We conducted the pilot test on a small sample in a school. We used a self-reported questionnaire to ensure the reliability and validity of the intervention, which might create the possibility of response bias. However, it would have great implications in the field of tobacco control program. It would add a new dimension to designing school-level curriculum regarding tobacco control. Conclusion We developed a highly reliable and valid protection motivation theory-based health education intervention based on the needs of students. It had ten sessions, including a quiz contest and concluding session. Each session took forty-five minutes to complete, except for the quiz contest and concluding session. Proper implementation of this intervention would enhance students’ knowledge and skills regarding SLT and help them apply these in their lives. Therefore, local bodies and school stakeholders should include this intervention in their policies and programs. Abbreviations PhD Philosophy of Doctor PMT Protection Motivation Theory SLT Smokeless Tobacco UGC University Grant Commission Declarations Ethical approval and consent to participate Ethical approval for the study was obtained from Ethical Review Board of the Nepal Health Research Council, Kathmandu, Nepal (Ref. No.: 3067). Informed written consent from Head Teacher and parents of students, and assents from students of selected school was taken before the pilot test. This study adhered the declaration of Helsinki. The confidentiality of participants and freedom of them to participate or leave the study were assured. The situation of no any harm such as physical, mental and educational to the participants was maintained. Consent for publication Not applicable. Availability of data and materials The data used for the current study will be available from the corresponding author on reasonable request. Competing interests Authors declare that they have no conflict of interest. Funding The University Grant Commission (UGC), Nepal, has provided funds to conduct research. AKM has received a PhD Fellowship and Research Support Grant (PhD-79/80-Edu-06) from UGC. However, the UGC has no role in conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript. Authors’ contribution AKM conceptualized and designed the study, collected data, analyzed data, wrote initial and final manuscript. CBB modified the design, provided necessary inputs to data analysis, made necessary corrections in the manuscript. Both authors checked and approved the manuscript and decided to publish. Acknowledgements I am grateful to UGC Nepal for providing me a research grant to conduct my PhD research. I am indebted to the school administration, students who participated in the study, and their parents for providing their approval for the study. References Gupta PC, Sinha DN, Arora M, Asma S. Smokeless tobacco and public health in India: Executive summary. Smokeless Tobacco and Public Health in India. edn. New Delhi: Ministry of Health and Family Welfare Government of India; 2017. https://www.researchgate.net/publication/314154607_Smokeless_ Tobacco_and_Public_ Health_in_India_Executive_Summary . Bajracharya B, Khadka BB, Thapa B. Review of tobacco products used in Nepal especially giving emphasis on smokeless tobacco products. In. Kathmandu: National Health Education, Information and Communication Center, Ministry of Health and Population, Government of Nepal and World Health Organization Nepal.; 2011. https://doi.org/10.13140/RG.2.2.34773.58081/1 Sinha DN, Bajracharya B, Khadka BB, Rinchen S, Bhattad VB, Singh PK. Smokeless tobacco use in Nepal. Indian J Cancer. 2012;49(4):352–6. https://doi.org/10.4103/0019-509X.107728 . Bhisey RA, Stanfill SB. Chemistry and toxicology of smokeless tobacco. In: Smokeless Tobacco and Public Health in India. edn. Edited by Gupta PC, Arora M, Sinha D, Asma S, Parascondola M: Ministry of Health and Family Welfare Government of India; 2016. https://nhm.gov.in/NTCP/Surveys-Reports-Publications/Smokeless_Tobacco_and_Public_Health_in_India.pdf Shastri S, Chaturvedi P, Datta S, Shastri A. Smokeless tobacco use and cancer. In: Smokeless Tobacco and Public Health in India. edn. Edited by Gupta PC, Arora M, Sinha D, Asma S, Parascondola M: Mininstry of Health and Family Welfare Government of India; 2016. https://nhm.gov.in/NTCP/Surveys-Reports-Publications/Smokeless_Tobacco_and_Public_Health_in_India.pdf Salahuddin S, Mohan S, Roy A, Reddy KS. Cardiovascular diseases and other health consequences of smokeless tobacco use. In: Smokeless Tobacco and Public Health in India. edn. Edited by Gupta PC, Arora M, Sinha D, Asma S, Parascondola M: Ministry of Health and Family Welfare Government of India; 2016. https://nhm.gov.in/NTCP/Surveys-Reports-Publications/Smokeless_Tobacco_and_Public_Health_in_India.pdf Mathur V, Gupta T, Mathur MR, Murti PR. Oral health consequences of smokeless tobacco use. In: Smokeless Tobacco and Public Health in India. edn. Edited by Gupta PC, Arora M, Sinha D, Asma S, Parascondola M: Ministry of Health and Family Welfare Government of India; 2016. https://nhm.gov.in/NTCP/Surveys-Reports-Publications/Smokeless_Tobacco_and_Public_Health_in_India.pdf Siddiqi K, Vidyasagaran AL, Croucher R. A policy perspective on the global use of smokeless tobacco. Curr Addict Rep. 2017;4(4):503–10. https://doi.org/10.1007/s40429-017-0166-7 . : Smokeless tobacco and public health: A global perspective. In National Cancer Institute and Centers for Disease Control and Prevention, Bethesda MD. 2014. https://cancercontrol.cancer.gov/brp/tcrb/global-perspective/SmokelessTobaccoAndPublicHealth.pdf Mishu MP, Siddiqi K, McNeill A, Kanaan M, Jackson C, Huque R, Kanan S, Abdullah SM, Fieroze F, Garg S et al. Assessing the impact of tobacco control policies on smokeless tobacco uptake and use among secondary school students in South Asia: Protocol for a feasibility study of conducting longitudinal surveys [version 1; peer review: 2 approved with reservations]. F1000Research 2020, 9. https://doi.org/10.12688/f1000research.25796.1 Yadav A, Singh PK, Yadav N, Kaushik R, Chandan K, Chandra A, Singh S, Garg S, Gupta PC, Sinha DN, et al. Smokeless tobacco control in India: Policy review and lessons for high-burden countries. BMJ Global Health. 2020;5(7):e002367. https://doi.org/10.1136/bmjgh-2020-002367 . American Psychological Association: Developing adolescents: A reference for professionals. In. 2002. https://www.apa.org/pi/families/resources/develop.pdf Nichols AJ. The influence of a school-based substance abuse prevention program in reducing smoking among sixth grade African American students in Louisiana Doctoral dissertation. University of California at Los Angeles; 2006. Curriculum Development Center. Guidelines for school health programs to prevent tobacco use and addiction. In. 1994;43:1–18. https://www.cdc.gov/mmwr/preview/mmwrhtml/00026213.htm . Kishore J, Jena P. Trend in smokeless tobacco use among youth in SEA region (2003–2016)[Abstract]. Tobacco induced diseases 2018, 16(1). https://doi.org/10.18332/tid/84317 Thrul J, Stemmler M, Buhler A, Kuntsche E. Adolescents' protection motivation and smoking behaviour. Health Educ Res. 2013;28(4):683–91. https://doi.org/10.1093/her/cyt062 . Madihie A, Noah SM. An Application of the Sidek Module Development in Rebt Counseling Intervention Module Design for Orphans. Procedia - Social Behav Sci. 2013;84:1481–91. https://doi.org/10.1016/j.sbspro.2013.06.777 . Maddux JE, Rogers RW. Protection motivation and self-efficacy: A revised theory of fear appeals and attitude change. J Exp Soc Psychol. 1983;19(5):469–79. https://doi.org/10.1016/0022-1031(83)90023-9 . Rogers RW. A protection motivation theory of fear appeals and attitude change. J Psycholy. 1975;91(1):93–114. https://doi.org/10.1080/00223980.1975.9915803 . Rogers RW. Cognitive and physiological processes in fear appeals and attitude change: A revised theory of protection motivation. In: Social Psychophysiology: A Sourcebook. edn. Edited by Cacioppo JT, Petty RE: Guilford; 1983. https://www.researchgate.net/publication/229068371_Cognitive_and_ physiological_processes_in_ fear_appeals_and_attitude_change_A_revised_theory_of_protection_motivation Lau XC, Wong YL, Wong JE, Koh D, Sedek R, Jamil AT, Ng ALO, Hazizi AS, Ruzita AT, Poh BK. Development and validation of a physical activity educational module for overweight and obese adolescents: CERGAS programme. Int J Environ Res Public Health. 2019;16:1506. https://doi.org/10.3390/ijerph16091506 . Ali A, Amat S, Kari DNPM. Validity and reliability of the soft skills psychoeducation intervention module. Int J Innov Creativity Change 2019, 7(12). Ballal K, Kulkarni M, Agrawal A, Kamath A, Kumar M. Knowledge and attitude regarding tobacco and its use among adolescent students. Natl J Community Med. 2016;7(6):519–23. Sreeramareddy CT, Kishore P, Paudel J, Menezes RG. Prevalence and correlates of tobacco use amongst junior collegiates in twin cities of western Nepal: A cross-sectional, questionnaire-based survey. BMC Public Health. 2008;8:97. https://doi.org/10.1186/1471-2458-8-97 . Wang LY, Crossett LS, Lowry R, Sussman S, Dent CW. Cost-effectiveness of a school-based tobacco-use prevention program. Arch Pediatr Adolesc Med. 2001;155:1043–50. Tahlil T, Woodman RJ, Coveney J, Ward PR. The impact of education programs on smoking prevention: A randomized controlled trial among 11 to 14 year olds in Aceh, Indonesia. BMC Public Health. 2013;13:367. Reed D, Bowen E, Fint-Clark B, Clark B, Cobb N, Danberry KM, Hutson Z, Lusk S, Rine J, Robinson N. Stopping smokeless tobacco use: A call to action. Frontries Public Health. 2021;9:601890. https://doi.org/10.3389/fpubh.2021.601890 . Lin B, Liu X, Lu W, Wu X, Li Y, Zhang Z, Fu R, Zhang L, Xiong J. Prevalence and associated factors of smoking among Chinese adolescents: A school-based cross-sectional study. BMC Public Health. 2023;23. https://doi.org/10.1186/s12889-023-15565-3 . Jiloha RC. Tobacco use and health behavior. In. New Delhi, Bangalore, Chennai, Cochin, Guwahati, Hyderabad, Jalandhar, Kolkata, Lucknow, Mumbai. Ranchi: New Age International; 2008. Chatterjee N, Gupte H, Mandal G, Bhutia T. Does adding a psychosocial cessation intervention to an existing life-skills and tobacco-prevention program influence the use of tobacco and supari among secondary school students? Findings from a quasi-experimental trial in Mumbai, India. Tob Prev Cessat. 2019;5:45. https://doi.org/10.18332/tpc/113355 . Hawsawi A. Tobacco Use, Second Hand Smoke Exposure and Associated Factors among Saudi Arabian Middle School Students: A Cross-Sectional Study. Dr.H.Sc. Ann Arbor: Indiana State University; 2020. Bandura A. Social cognitive theory: An agentic perspective. Asian J Soc Psychol. 1999;2:21–41. Lund L, Bast LS, Rubæk M, Andersen S. Exploring factors associated with smokeless tobacco use among young people: A systematic scoping review. Drug Alcohol Depend. 2022;240:109627. https://doi.org/10.1016/j.drugalcdep.2022.109627 . Mall ASK, Bhagyalaxmi A. An informal school-based, peer-led intervention for prevention of tobacco consumption in adolescence: A cluster randomized trial in rural Gandhinagar. Indian J Community Med. 2017;42:143–6. https://doi.org/10.4103/ijcm.IJCM_25_16 . Family Health Division. National adolescent health and development strategy. In. Nepal: Department of Health Services, Ministry of Health, His Majesty's Government of Nepal; 2000. https://mohp.gov.np/downloads/Adolescent%20Health%20Strategy.pdf . Peace Corps Information Collection and Exchange, United States Agency International Development. Life skills and leadership manual. In. Washington, DC: Peace Corps Information Collection and Exchange and United States Agency International Development; n.d. https://files.peacecorps.gov/library/M0098.pdf Teles LMR, de Oliveira AS, Campos FC, Lima TM, da Costa CC, Gomes LFS, Oria MOB. Damasceno AKdC: Development and validating an educational booklet for childbirth companions. Rev Esc Enferm USP. 2014;48(6):977–84. https://doi.org/10.1590/S0080-623420140000700003 . Additional Declarations No competing interests reported. Supplementary Files Additionalfile1.pdf Additionalfile2.pdf Cite Share Download PDF Status: Published Journal Publication published 23 Dec, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 05 Aug, 2025 Reviews received at journal 24 Jul, 2025 Reviews received at journal 15 Jul, 2025 Reviewers agreed at journal 13 Jul, 2025 Reviewers agreed at journal 13 Jul, 2025 Reviewers agreed at journal 12 Jul, 2025 Reviewers invited by journal 11 Jul, 2025 Editor assigned by journal 11 Jul, 2025 Editor invited by journal 03 Jul, 2025 Submission checks completed at journal 02 Jul, 2025 First submitted to journal 02 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6891275","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":484812685,"identity":"b42e276a-f76c-400c-ba27-b9353489f1cb","order_by":0,"name":"Anil Kumar Mandal","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCUlEQVRIiWNgGAWjYFACxsYDYPoAc+MDhCgbXi0NUC2MzQYI1Xi1ABVDtbRJEKWFf3ZzwwHGHLs8vuMH2yp//NkmzyDfY8Dwoewwg7l0A1YtEncOArVsSy6WPJPYdpu37bZhAxuPAeOMc4cZLOccwG7NjUSQFubEDQeAWhgbbicwALUw87YdZjC4kYBVhzxES33ihvMP2wp//IFq+YtHiwFEy+HEDTcS2xh42KBaGPFoMQRpSdx2PHHmjYfN0iC/tLGlFRzsOZfOY3AHu1/kbqQ/fPBxW3Vi3/nkgx+BDpPnZz688cGPMms5g9vYQwwMUBwAihGQ8TwMErh14AJkaBkFo2AUjIJhCQCR+WoPHgSSlAAAAABJRU5ErkJggg==","orcid":"","institution":"Tribhuvan University","correspondingAuthor":true,"prefix":"","firstName":"Anil","middleName":"Kumar","lastName":"Mandal","suffix":""},{"id":484812686,"identity":"de74e785-f503-4135-bae7-9c00bf4466c9","order_by":1,"name":"Chitra Bahadur Budhathoki","email":"","orcid":"","institution":"Tribhuvan University","correspondingAuthor":false,"prefix":"","firstName":"Chitra","middleName":"Bahadur","lastName":"Budhathoki","suffix":""}],"badges":[],"createdAt":"2025-06-14 02:08:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6891275/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6891275/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-26000-0","type":"published","date":"2025-12-23T15:58:18+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":99172494,"identity":"278a32e4-74ab-44f5-ac37-8a7af240596c","added_by":"auto","created_at":"2025-12-29 16:10:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":731191,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6891275/v1/4a7a2d67-ef55-4b7e-93f9-52a69cf55e15.pdf"},{"id":86799390,"identity":"c313c478-f365-4a71-bded-d00d5c96f8c4","added_by":"auto","created_at":"2025-07-15 16:35:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":121701,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6891275/v1/d6b663c9ec123f0292b8e99d.pdf"},{"id":86799393,"identity":"79cf0efb-2a78-4032-b3df-d458bcddc1e1","added_by":"auto","created_at":"2025-07-15 16:35:54","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":157413,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6891275/v1/81c38ab7cc09a66a40eb0b1d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Developing a Theory-based Health Education Intervention to Prevent Adolescent Students from Smokeless Tobacco Consumption","fulltext":[{"header":"Background","content":"\u003cp\u003eSmokeless tobacco (SLT) is a kind of tobacco that is consumed through the mouth or nose without candling it [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and is also known as spitting tobacco [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. \u003cem\u003eKhaini\u003c/em\u003e/\u003cem\u003esurti\u003c/em\u003e, \u003cem\u003eGutkha\u003c/em\u003e, \u003cem\u003eZarda\u003c/em\u003e, \u003cem\u003ePaan\u003c/em\u003e containing tobacco constituents (\u003cem\u003ebetel quid\u003c/em\u003e) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], \u003cem\u003etobacco leaf\u003c/em\u003e, \u003cem\u003ekiwam\u003c/em\u003e [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], \u003cem\u003esnuff\u003c/em\u003e, and \u003cem\u003egul\u003c/em\u003e [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] are different types of SLT. It contains approximately four thousand toxic, mutagenic, and carcinogenic chemicals along with highly addictive \u003cem\u003eNicotine\u003c/em\u003e [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Cancer of the mouth and pharynx [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], heart diseases [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], and inflammation of gingiva, decaying of teeth, oral submucous fibrosis, and development of leukoplakia [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] are attributed to consumption of SLT.\u003c/p\u003e\u003cp\u003eSLT consumption is detrimental to health, but over 300\u0026nbsp;million people in the world are consuming SLT [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and attracting more adolescents towards it [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Although it has created a compound and pervasive challenge to health and economy, especially in low- and middle-income countries (LMICs) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], the researchers and policymakers are not seen focusing on it, and still the international efforts of tobacco control are mostly centered on cigarettes rather than other forms of tobacco [\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e–\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. They neglect it because SLT is considered less harmful than smoking and is a regional problem that is more complicated to control [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Similarly, dodging the laws against tobacco and advertising SLT as the alternative to cigarette smoking to maintain nicotine levels by manufacturer companies of SLT are helpful for smoking cessation programs, but it ultimately increases the consumption rate of SLT [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAdolescents are considered as more vulnerable to risk-taking behavior [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and consumption of tobacco is a door for drugs such as marijuana and cocaine [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] and alcohol. And consumption of SLT is increasing among youths of Nepal compared to youths of other East Asian countries [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. All these facts indicate that adolescents should be awakened and equipped with knowledge and skills against SLT consumption. Besides it, only a few researchers have followed PMT [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]; this study aimed to develop PMT-based health education intervention to prevent adolescent students from consuming SLT.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy Design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDeveloping a draft of a module of an intervention, identifying its validity and reliability, and finalizing the draft are the stages of developing a module [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. A needs assessment, drafting the module of intervention, conducting a pilot test of intervention to assure its reliability and validity, and finalizing the module of the intervention were the procedures of development of health education intervention (HEI). Besides it, rigorous literature review and regular feedback from the supervisor were the means of developing intervention.\u003c/p\u003e\u003cp\u003e\u003cb\u003eProtection Motivation Theory (PMT)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eInitially, in 1975, Rogers developed PMT by including variables of fear appeals to expectancy-value theory [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and modified it in 1983 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Perception of severity, perception of vulnerability, perception of intrinsic rewards, perception of extrinsic rewards, perception of response efficacy, perception of self-efficacy, and perception of response cost are the constructs of modified PMT. The higher perception of severity, vulnerability, response efficacy, and self-efficacy and the lower perception of intrinsic and extrinsic rewards, and response cost raise the protection motivation that pushes to change the attitude and behavior of a person.\u003c/p\u003e\u003cp\u003e\u003cb\u003eNeeds Assessment\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe needs assessment was conducted before drafting the module of the intervention. For this, we conducted four focus group discussions (FGD) among the students of Class 9 in a separate classroom to prevent disturbances like noise. We developed guidelines for FGDs (see Additional file 1) based on the constructs of PMT and followed them. In each FGD, 7–9 students participated. FGDs were conducted in both Nepali and Maithili languages till the point of saturation [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], where little or no new opinions arise, and lasted from 50 minutes to one hour. A mobile, model Vivo 27, was used to audio record it. The audio records of FGDs were transcribed into the Nepali language. The transcripts were read many times to make sense. Themes were extracted from the transcripts of the FGDs by following the sequence of codes, categories, and themes, and then it was translated into the English language.\u003c/p\u003e\u003cp\u003e\u003cb\u003eDrafting of Intervention\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe module of the intervention was drafted based on the objectives, guided theory, target group and their needs, and time allocated for the study [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] including insights from literature, feedback from the supervisor, insights gained from the pilot test and suggestions from student during informal talks.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePilot Test of Intervention\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA pilot test of the intervention, two sessions each week, was conducted among 20 to 25 students of Class 9. Each session took 45 minutes to complete, but the first and concluding sessions. The first session took 90 minutes. In this way, the pilot test was completed in 4 weeks, including one extra concluding session in the fourth week. Only data of 16 students (boys-7, girls-9), who were present in each session, was analyzed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eReliability of Intervention\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe questionnaire based on the objectives of the module is used for identifying its reliability (Jamaludin Ahmad and Sidek Mohd Noah, 2001) [as cited in 17]. We developed and used a self-reported questionnaire based on the objectives of each session—except the 10th session—to calculate Cronbach’s alpha to identify the reliability of the intervention (see Additional file 2). The questionnaire contained 72 items, three for each of the 24 objectives of 8 sessions. The questionnaire was a five-point Likert scale type, ranging from strongly disagree (1) to strongly agree (5). After 1 week of finishing the pilot test of the intervention, data was collected by administering questionnaires among the students. The guidance was facilitated by the researcher on any confusion or difficulties related to questions. After collection of data, it was edited and entered into Statistical Package for Social Science (SPSS) version 20 to calculate Cronbach’s alpha to assure the reliability of the module of the intervention.\u003c/p\u003e\u003cp\u003e\u003cb\u003eValidity of Intervention\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThrough literature and experts [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], content validity was ensured. For this, regular feedback was received from the supervisor, and a rigorous literature review was performed. The participants of the pilot test, a subgroup of the study population [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], were the means for ensuring face validity of the contents of the intervention. We developed a self-reported five-point Likert-scale-type questionnaire ranging from strongly disagree (1) to strongly agree (5) along with the questionnaire for the reliability test of the intervention (see Additional file 2), and administered among the students to identify the face validity of the module of the intervention. It contained 7 items related to contents, activities, teaching materials, and time allocated for the sessions. But it was analyzed by categorizing it into disagree, neutral, and agree. Likewise, informal 3- to 5-minute talks with 3 students about the contents and activities of the modules of the intervention were done to assure the face validity of the module.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe draft of the module of the protection motivation theory-based health education intervention was developed. Through FGDs, themes were derived in the line of constructs of PMT. Knowledge related to SLT, effects of SLT consumption (severity of SLT), hazards of SLT consumption (vulnerability of SLT), misconceptions related to rewards of SLT consumption (intrinsic and extrinsic rewards), preventive measures of SLT consumption (response efficacy), skills needed to prevent SLT consumption (self-efficacy), misconceptions related to the cost of not consuming SLT (response cost), and peer as the source of SLT consumption were the themes derived from FGDs.\u003c/p\u003e\u003cp\u003eWe found that many students had not sufficient knowledge regarding SLT. They considered tobacco, alcohol, and drugs as tobacco. They thought that smoked and smokeless tobacco were the same. They were not aware of the harmful chemicals found in SLT and its effects. They thought that almost all people consume tobacco, and more people who do not consume tobacco are suffering from cancer and dying than those who consume tobacco. Some of them also thought that not consuming SLT is good for health. They mentioned that consuming SLT is relaxing and prestigious among people. They accepted that peer pressure was a dominating factor of consuming SLT. They realized the need for life skills to prevent SLT consumption. They echoed the need for an awareness program and implementation of strict rules in school settings to prevent tobacco use.\u003c/p\u003e\u003cp\u003e\u003cb\u003eDrafting and Finalization of Intervention\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBefore the pilot test, HEI had 9 sessions, including 1 concluding session. For each of the 7 constructs of PMT, one session of intervention was drafted, except for self-efficacy, which had 2 sessions.\u003c/p\u003e\u003cp\u003eAfter the pilot test, we slightly modified HEI. The 1st session was divided into two sessions, the third and the fourth sessions were merged into one session, and the seventh session was divided into two sessions. It had 10 sessions without altering the contents and objectives, which it had before the pilot test, including a quiz contest and concluding session. Session 1st had focused on knowledge related to tobacco and SLT. Session 2nd was related to the severity of SLT consumption, session 3rd was related to the vulnerability of SLT, session 4th was related to the extrinsic and intrinsic rewards of SLT, session 5th was related to response cost, session 6th was related with response efficacy, and sessions 7th, 8th, and 9th were concerned with self-efficacy. In this way, contents related to each of the seven constructs of PMT had been included in the intervention. The 10th session was a quiz contest and concluding session, which was related to the contents of sessions 1 through 9 to solidify the knowledge and skills acquired by students in each session. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e images the final number of sessions with contents and objectives of the intervention after the pilot test.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSessions of the intervention with contents and objectives\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSessions\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eContents\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eObjectives\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. Introduction to Smokeless Tobacco\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Introduction\u003c/p\u003e \u003cp\u003e- Types of SLT\u003c/p\u003e\u003cp\u003e- Chemical Found in SLT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- Introduce smokeless tobacco\u003c/p\u003e \u003cp\u003e- identify different types of SLT\u003c/p\u003e \u003cp\u003e- list chemical found in SLT\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. Prevalence and Effects of SLT Consumption\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Prevalence of SLT\u003c/p\u003e\u003cp\u003e- Short term effects of SLT\u003c/p\u003e\u003cp\u003e- Long term effects of SLT\u003c/p\u003e\u003cp\u003e- Mortality Caused by Tobacco\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- explain proportion of people who consume smokeless tobacco\u003c/p\u003e\u003cp\u003e- describe short terms effects of SLT\u003c/p\u003e\u003cp\u003e- describe long terms effects of SLT\u003c/p\u003e\u003cp\u003e- describe mortality caused by tobacco\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. Addiction and Hazards of SLT Consumption\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Addiction of SLT\u003c/p\u003e\u003cp\u003e- Probability of Hazards Caused by SLT Consumption\u003c/p\u003e\u003cp\u003e- Positive Aspects of not Consuming SLT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- explain the process of addiction due to SLT consumption\u003c/p\u003e\u003cp\u003e- describe the probability of hazards caused by SLT consumption\u003c/p\u003e\u003cp\u003e- list the positive aspects of not consuming SLT\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. Misconception Related to Rewards of SLT Consumption\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Misconceptions Related to Intrinsic Rewards of SLT Consumption\u003c/p\u003e\u003cp\u003e- Misconceptions Related to Intrinsic Rewards of SLT Consumption\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- identify misconceptions related to intrinsic rewards of SLT consumption\u003c/p\u003e\u003cp\u003e- explain misconceptions related to extrinsic rewards of SLT consumption\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. Misconception Related to Cost Paid for not Consuming SLT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Misconceptions Related to Cost Paid for not Consuming SLT\u003c/p\u003e\u003cp\u003e- Social/Group Norms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- describe misconceptions related to cost paid for not consuming SLT\u003c/p\u003e \u003cp\u003e- able to differentiate positive and negative group norms\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6. Preventive Measures of SLT Consumption\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Preventive Measures of SLT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- explain preventive measures of SLT consumption\u003c/p\u003e\u003cp\u003e- accept the importance of prescribed behaviors to prevent from SLT consumption\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7. Decision Making\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Introduction of Decision Making\u003c/p\u003e\u003cp\u003e- Steps of Decision Making\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- describe decision making\u003c/p\u003e\u003cp\u003e- list the steps of decision making\u003c/p\u003e\u003cp\u003e- able to apply the steps of decision making in their behavior\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8. Peer Pressure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Introduction of Peer Pressure\u003c/p\u003e\u003cp\u003e- Ways of Coping Peer Pressure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- describe peer pressure\u003c/p\u003e\u003cp\u003e- explain the ways of coping peer pressure\u003c/p\u003e\u003cp\u003e- able to apply the ways of coping peer pressure in behavior\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9. Saying \u0026lsquo;NO\u0026rsquo; SLT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Introduction of Saying \u0026lsquo;NO\u0026rsquo; SLT\u003c/p\u003e\u003cp\u003e- Different Ways of Saying \u0026lsquo;NO\u0026rsquo; SLT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- describe different ways of saying \u0026lsquo;NO\u0026rsquo; SLT\u003c/p\u003e\u003cp\u003e- able to apply the different ways of saying \u0026lsquo;NO\u0026rsquo; in their behavior\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10. Quiz Contest and Concluding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e- Quiz Related to above Sessions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e- to solidify the knowledge and skill achieved in the previous sessions\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eReliability of Intervention\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCronbach alpha values of each objective of respective sessions were high and acceptable, ranging from .807 to .880. Cronbach alpha values for each objective are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eObjective wise Cronbach Alpha of each session\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSessions\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo. of objectives for each session\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo. of questions for each objectives\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eValue of Cronbach Alpha\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e1. Introduction to Smokeless Tobacco\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.824\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.826\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.857\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e2. Prevalence and Effects of SLT Consumption\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.880\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.842\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.815\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.815\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e3. Addiction and Hazards of SLT Consumption\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.824\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.828\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.864\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e4. Misconceptions Related to Rewards of SLT Consumption\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.822\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.865\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e5. Misconceptions Related to Cost Paid for not Consuming SLT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.867\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.807\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e6. Preventive Measures of SLT Consumption\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.827\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.814\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e7. Decision Making\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.817\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.858\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.818\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e8. Peer Pressure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.836\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.821\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.838\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e9. Saying \u0026lsquo;NO\u0026rsquo; SLT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.846\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.846\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eValidity of Intervention\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMore than 80% of students agreed to the effectiveness and appropriateness of all components except the time allocated for each session. Less than 70% of students agreed to the time allocated for each session. During informal talks with students, they mainly suggested breaking down the first session into two sessions and merging the session third and the session fourth into one session. Agreement percentages by participants for each component of the sessions are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eAgreement percentages for each component of the sessions\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComponents\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eD (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eA (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe contents were clear and understandable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e87.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe contents were useful to meet the needs of students\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e93.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe contents meet the learning standard of students\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e87.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe learning materials are clear and readable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e87.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe teaching-learning activities were appropriate to meet the needs of students\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e87.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe teaching-learning activities created the opportunity for active learning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e87.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe time allocated for each session was appropriate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e31.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eD: Disagree; A: Agree\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eInadequate knowledge regarding tobacco use might lead to undesired attitudes [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. But, we found students had insufficient knowledge regarding tobacco, SLT, and its impact on health. Only a few of them were known to chemicals found in SLT, which are responsible for addiction and diseases like cancer. Besides it, they were misinformed about the probability of hazards of SLT consumption, misconceptions about rewards related to SLT consumption, and misconceptions related to cost paid on not consumption of SLT. Therefore, information related to it was included in the sessions of HEI.\u003c/p\u003e\u003cp\u003eIncluding the contents related to different aspects of SLT in the intervention might have a positive impact on the SLT consumption behavior of students because knowledge about the harms of tobacco is one of the protective factors of its consumption [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Not only this, Wang et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] reported that the school-based tobacco use prevention program \u0026lsquo;towards no tobacco use (TNT)\u0026rsquo; was a more highly cost-effective intervention than other prevention programs. Similarly, Tahil et al. [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] found that school-based smoking intervention raises the knowledge related to ill impacts of smoking and enhances the negative attitude towards smoking among students. Likewise, Reed et al. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] assessed a spit tobacco prevention curriculum conducted in West Virginia and found that the implementation of the curriculum had a positive impact on the knowledge of students regarding tobacco consumption. Therefore, we can say that providing knowledge about SLT might increase the level of knowledge of students.\u003c/p\u003e\u003cp\u003eHaving misconceptions regarding the rewards of SLT consumption and the cost paid for not consuming SLT are the significant factors of its consumption. Considering smoking as attractive and convenient at social activities are significant factors of smoking [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. People consume tobacco as a stress reducer, and some people consume tobacco to maintain body weight [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] to look fit and smarter. However, a study [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] showed that very few students perceived tobacco consumption as a cool, comfortable enhancer and stress reducer; some people accept that tobacco consumers have more friends. Likewise, personal attitude towards tobacco and social norms are significant contributors to tobacco use [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In the FGDs, students voiced such misconceptions related to SLT consumption; therefore, information about such misconceptions was included in the intervention.\u003c/p\u003e\u003cp\u003eSkills are necessary to practice on the knowledge achieved and attitude developed. Social cognitive theory [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] emphasizes the need and importance of self-efficacy to perform action. It accepts perception of self-efficacy as a vital component to have mastery over desired action or behavior. Maddux and Rogers [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] emphasized self-efficacy as one of the main constructs of PMT to achieve desired behavior. But the FGDs showed that participants had no sufficient skills related to decision-making, how to cope with peer pressure, and how to say \u0026lsquo;NO\u0026rsquo; to proposals of SLT consumption from their peers. They felt hesitation regarding these skills that are necessary to keep themselves away from SLT consumption. All of them accepted the need for skills that prevent SLT consumption. Keeping it in mind, some life skills such as decision-making, coping with peer pressure, and saying \u0026lsquo;NO\u0026rsquo; to SLT were included in the sessions of HEI. This intervention might have a positive impact on SLT consumption behavior of students because after assessing the spit tobacco prevention program conducted in West Virginia, Reed et al. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] reported that the implementation of the curriculum had a positive impact on tobacco consumption behavior of students. They mentioned that almost all students were able to list the things to purchase instead of spit tobacco, to say no to their friends who offered spit tobacco to them, and to get more involved in the prevention of spit tobacco use in their school or community.\u003c/p\u003e\u003cp\u003eParticipants of FGDs accepted peers as the main source of SLT consumption. Therefore, contents related to peer pressure and how to refuse the proposal of a peer to consume SLT were included in the intervention. Many studies have shown the effectiveness of peer-oriented intervention. Because Lund et al. [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] had emphasized that prevention programs should focus on the role of peers and family to control it. Similarly, a peer-led, school-based tobacco control intervention has a significant effect on reducing SLT consumption [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAdolescence is a transitional period between the stages of childhood and adulthood of life, and they might be involved in risk behaviors [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], and they might be incapable of making the right decision. In this period, they need a guideline for the right decision. In the lack of capability of decision-making, they might be involved in risks such as SLT consumption. They might be engaged in destructive works rather than positive and creative works. The capability of decision-making skills is an asset of youths and a symbol of positive identity and social competencies that leads them to constructive and positive behavior [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Therefore, it is necessary to enhance their capacity of decision-making to prevent them from risk-taking behaviors like consumption of SLT.\u003c/p\u003e\u003cp\u003eResearchers have no consistency regarding the value of Cronbach\u0026rsquo;s Alpha to set the standard of reliability of intervention. Good and acceptable values of Cronbach\u0026rsquo;s Alpha varied from .60 to .80 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and from .65 to .90 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. We found high and acceptable reliability for the intervention because no sessions had a Cronbach\u0026rsquo;s Alpha value less than 0.8.\u003c/p\u003e\u003cp\u003eWe obtained high face validity for the components of the sessions of the intervention. Almost all students agreed with the contents and learning activities included in the sessions of intervention. However, some (one-third) of the students disagreed with the time allocated for the session, especially the first session, which was modified. It needs an agreement percentage of 75 to be valid, and the agreement percentage below 75 needs to be revised [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In this regard, the first session was divided into two sessions, the third session and the fourth session were merged into one session, and three sessions were separated for self-efficacy to manage time.\u003c/p\u003e\u003cp\u003eThis study was not free from limitations. Needs assessment was limited to the constructs of PMT. In the intervention, we only included how to cope with peer pressure, how to make decisions, and how to say \u0026lsquo;NO\u0026rsquo; SLT among the various life skills. It had limited sessions and time duration. We conducted the pilot test on a small sample in a school. We used a self-reported questionnaire to ensure the reliability and validity of the intervention, which might create the possibility of response bias. However, it would have great implications in the field of tobacco control program. It would add a new dimension to designing school-level curriculum regarding tobacco control.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe developed a highly reliable and valid protection motivation theory-based health education intervention based on the needs of students. It had ten sessions, including a quiz contest and concluding session. Each session took forty-five minutes to complete, except for the quiz contest and concluding session. Proper implementation of this intervention would enhance students\u0026rsquo; knowledge and skills regarding SLT and help them apply these in their lives. Therefore, local bodies and school stakeholders should include this intervention in their policies and programs.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePhD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePhilosophy of Doctor\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePMT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eProtection Motivation Theory\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSLT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSmokeless Tobacco\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eUGC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUniversity Grant Commission\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the study was obtained from Ethical Review Board of the Nepal Health Research Council, Kathmandu, Nepal (Ref. No.: 3067). Informed written consent from Head Teacher and parents of students, and assents from students of selected school was taken before the pilot test. This study adhered the declaration of Helsinki. The confidentiality of participants and freedom of them to participate or leave the study were assured. The situation of no any harm such as physical, mental and educational to the participants was maintained.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used for the current study will be available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe University Grant Commission (UGC), Nepal, has provided funds to conduct research. AKM has received a PhD Fellowship and Research Support Grant (PhD-79/80-Edu-06) from UGC. However, the UGC has no role in conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAKM conceptualized and designed the study, collected data, analyzed data, wrote initial and final manuscript. CBB modified the design, provided necessary inputs to data analysis, made necessary corrections in the manuscript. Both authors checked and approved the manuscript and decided to publish.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI am grateful to UGC Nepal for providing me a research grant to conduct my PhD research. I am indebted to the school administration, students who participated in the study, and their parents for providing their approval for the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGupta PC, Sinha DN, Arora M, Asma S. Smokeless tobacco and public health in India: Executive summary. Smokeless Tobacco and Public Health in India. edn. New Delhi: Ministry of Health and Family Welfare Government of India; 2017. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchgate.net/publication/314154607_Smokeless_ Tobacco_and_Public_ Health_in_India_Executive_Summary\u003c/span\u003e\u003cspan address=\"https://www.researchgate.net/publication/314154607_Smokeless_Tobacco_and_Public_Health_in_India_Executive_Summary\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBajracharya B, Khadka BB, Thapa B. Review of tobacco products used in Nepal especially giving emphasis on smokeless tobacco products. In. Kathmandu: National Health Education, Information and Communication Center, Ministry of Health and Population, Government of Nepal and World Health Organization Nepal.; 2011. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.13140/RG.2.2.34773.58081/1\u003c/span\u003e\u003cspan address=\"10.13140/RG.2.2.34773.58081/1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSinha DN, Bajracharya B, Khadka BB, Rinchen S, Bhattad VB, Singh PK. Smokeless tobacco use in Nepal. Indian J Cancer. 2012;49(4):352\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4103/0019-509X.107728\u003c/span\u003e\u003cspan address=\"10.4103/0019-509X.107728\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBhisey RA, Stanfill SB. Chemistry and toxicology of smokeless tobacco. In: \u003cem\u003eSmokeless Tobacco and Public Health in India.\u003c/em\u003e edn. Edited by Gupta PC, Arora M, Sinha D, Asma S, Parascondola M: Ministry of Health and Family Welfare Government of India; 2016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://nhm.gov.in/NTCP/Surveys-Reports-Publications/Smokeless_Tobacco_and_Public_Health_in_India.pdf\u003c/span\u003e\u003cspan address=\"https://nhm.gov.in/NTCP/Surveys-Reports-Publications/Smokeless_Tobacco_and_Public_Health_in_India.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShastri S, Chaturvedi P, Datta S, Shastri A. Smokeless tobacco use and cancer. In: \u003cem\u003eSmokeless Tobacco and Public Health in India.\u003c/em\u003e edn. Edited by Gupta PC, Arora M, Sinha D, Asma S, Parascondola M: Mininstry of Health and Family Welfare Government of India; 2016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://nhm.gov.in/NTCP/Surveys-Reports-Publications/Smokeless_Tobacco_and_Public_Health_in_India.pdf\u003c/span\u003e\u003cspan address=\"https://nhm.gov.in/NTCP/Surveys-Reports-Publications/Smokeless_Tobacco_and_Public_Health_in_India.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalahuddin S, Mohan S, Roy A, Reddy KS. Cardiovascular diseases and other health consequences of smokeless tobacco use. In: \u003cem\u003eSmokeless Tobacco and Public Health in India.\u003c/em\u003e edn. Edited by Gupta PC, Arora M, Sinha D, Asma S, Parascondola M: Ministry of Health and Family Welfare Government of India; 2016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://nhm.gov.in/NTCP/Surveys-Reports-Publications/Smokeless_Tobacco_and_Public_Health_in_India.pdf\u003c/span\u003e\u003cspan address=\"https://nhm.gov.in/NTCP/Surveys-Reports-Publications/Smokeless_Tobacco_and_Public_Health_in_India.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMathur V, Gupta T, Mathur MR, Murti PR. Oral health consequences of smokeless tobacco use. In: \u003cem\u003eSmokeless Tobacco and Public Health in India.\u003c/em\u003e edn. Edited by Gupta PC, Arora M, Sinha D, Asma S, Parascondola M: Ministry of Health and Family Welfare Government of India; 2016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://nhm.gov.in/NTCP/Surveys-Reports-Publications/Smokeless_Tobacco_and_Public_Health_in_India.pdf\u003c/span\u003e\u003cspan address=\"https://nhm.gov.in/NTCP/Surveys-Reports-Publications/Smokeless_Tobacco_and_Public_Health_in_India.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSiddiqi K, Vidyasagaran AL, Croucher R. A policy perspective on the global use of smokeless tobacco. Curr Addict Rep. 2017;4(4):503\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s40429-017-0166-7\u003c/span\u003e\u003cspan address=\"10.1007/s40429-017-0166-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e: Smokeless tobacco and public health: A global perspective. In National Cancer Institute and Centers for Disease Control and Prevention, Bethesda MD. 2014. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://cancercontrol.cancer.gov/brp/tcrb/global-perspective/SmokelessTobaccoAndPublicHealth.pdf\u003c/span\u003e\u003cspan address=\"https://cancercontrol.cancer.gov/brp/tcrb/global-perspective/SmokelessTobaccoAndPublicHealth.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMishu MP, Siddiqi K, McNeill A, Kanaan M, Jackson C, Huque R, Kanan S, Abdullah SM, Fieroze F, Garg S et al. Assessing the impact of tobacco control policies on smokeless tobacco uptake and use among secondary school students in South Asia: Protocol for a feasibility study of conducting longitudinal surveys [version 1; peer review: 2 approved with reservations]. \u003cem\u003eF1000Research\u003c/em\u003e 2020, 9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.12688/f1000research.25796.1\u003c/span\u003e\u003cspan address=\"10.12688/f1000research.25796.1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYadav A, Singh PK, Yadav N, Kaushik R, Chandan K, Chandra A, Singh S, Garg S, Gupta PC, Sinha DN, et al. Smokeless tobacco control in India: Policy review and lessons for high-burden countries. BMJ Global Health. 2020;5(7):e002367. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjgh-2020-002367\u003c/span\u003e\u003cspan address=\"10.1136/bmjgh-2020-002367\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmerican Psychological Association: Developing adolescents: A reference for professionals. In. 2002. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.apa.org/pi/families/resources/develop.pdf\u003c/span\u003e\u003cspan address=\"https://www.apa.org/pi/families/resources/develop.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNichols AJ. The influence of a school-based substance abuse prevention program in reducing smoking among sixth grade African American students in Louisiana \u003cem\u003eDoctoral dissertation.\u003c/em\u003e University of California at Los Angeles; 2006.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCurriculum Development Center. Guidelines for school health programs to prevent tobacco use and addiction. In. 1994;43:1\u0026ndash;18. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/mmwr/preview/mmwrhtml/00026213.htm\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/mmwr/preview/mmwrhtml/00026213.htm\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKishore J, Jena P. Trend in smokeless tobacco use among youth in SEA region (2003\u0026ndash;2016)[Abstract]. \u003cem\u003eTobacco induced diseases\u003c/em\u003e 2018, 16(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.18332/tid/84317\u003c/span\u003e\u003cspan address=\"10.18332/tid/84317\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eThrul J, Stemmler M, Buhler A, Kuntsche E. Adolescents' protection motivation and smoking behaviour. Health Educ Res. 2013;28(4):683\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/her/cyt062\u003c/span\u003e\u003cspan address=\"10.1093/her/cyt062\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMadihie A, Noah SM. An Application of the Sidek Module Development in Rebt Counseling Intervention Module Design for Orphans. Procedia - Social Behav Sci. 2013;84:1481\u0026ndash;91. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.sbspro.2013.06.777\u003c/span\u003e\u003cspan address=\"10.1016/j.sbspro.2013.06.777\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMaddux JE, Rogers RW. Protection motivation and self-efficacy: A revised theory of fear appeals and attitude change. J Exp Soc Psychol. 1983;19(5):469\u0026ndash;79. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/0022-1031(83)90023-9\u003c/span\u003e\u003cspan address=\"10.1016/0022-1031(83)90023-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRogers RW. A protection motivation theory of fear appeals and attitude change. J Psycholy. 1975;91(1):93\u0026ndash;114. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/00223980.1975.9915803\u003c/span\u003e\u003cspan address=\"10.1080/00223980.1975.9915803\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRogers RW. Cognitive and physiological processes in fear appeals and attitude change: A revised theory of protection motivation. In: \u003cem\u003eSocial Psychophysiology: A Sourcebook.\u003c/em\u003e edn. Edited by Cacioppo JT, Petty RE: Guilford; 1983. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.researchgate.net/publication/229068371_Cognitive_and_ physiological_processes_in_ fear_appeals_and_attitude_change_A_revised_theory_of_protection_motivation\u003c/span\u003e\u003cspan address=\"https://www.researchgate.net/publication/229068371_Cognitive_and_physiological_processes_in_ fear_appeals_and_attitude_change_A_revised_theory_of_protection_motivation\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLau XC, Wong YL, Wong JE, Koh D, Sedek R, Jamil AT, Ng ALO, Hazizi AS, Ruzita AT, Poh BK. Development and validation of a physical activity educational module for overweight and obese adolescents: CERGAS programme. Int J Environ Res Public Health. 2019;16:1506. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/ijerph16091506\u003c/span\u003e\u003cspan address=\"10.3390/ijerph16091506\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAli A, Amat S, Kari DNPM. Validity and reliability of the soft skills psychoeducation intervention module. Int J Innov Creativity Change 2019, 7(12).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBallal K, Kulkarni M, Agrawal A, Kamath A, Kumar M. Knowledge and attitude regarding tobacco and its use among adolescent students. Natl J Community Med. 2016;7(6):519\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSreeramareddy CT, Kishore P, Paudel J, Menezes RG. Prevalence and correlates of tobacco use amongst junior collegiates in twin cities of western Nepal: A cross-sectional, questionnaire-based survey. BMC Public Health. 2008;8:97. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1471-2458-8-97\u003c/span\u003e\u003cspan address=\"10.1186/1471-2458-8-97\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang LY, Crossett LS, Lowry R, Sussman S, Dent CW. Cost-effectiveness of a school-based tobacco-use prevention program. Arch Pediatr Adolesc Med. 2001;155:1043\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTahlil T, Woodman RJ, Coveney J, Ward PR. The impact of education programs on smoking prevention: A randomized controlled trial among 11 to 14 year olds in Aceh, Indonesia. BMC Public Health. 2013;13:367.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eReed D, Bowen E, Fint-Clark B, Clark B, Cobb N, Danberry KM, Hutson Z, Lusk S, Rine J, Robinson N. Stopping smokeless tobacco use: A call to action. Frontries Public Health. 2021;9:601890. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3389/fpubh.2021.601890\u003c/span\u003e\u003cspan address=\"10.3389/fpubh.2021.601890\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLin B, Liu X, Lu W, Wu X, Li Y, Zhang Z, Fu R, Zhang L, Xiong J. Prevalence and associated factors of smoking among Chinese adolescents: A school-based cross-sectional study. BMC Public Health. 2023;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12889-023-15565-3\u003c/span\u003e\u003cspan address=\"10.1186/s12889-023-15565-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJiloha RC. Tobacco use and health behavior. In. New Delhi, Bangalore, Chennai, Cochin, Guwahati, Hyderabad, Jalandhar, Kolkata, Lucknow, Mumbai. Ranchi: New Age International; 2008.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChatterjee N, Gupte H, Mandal G, Bhutia T. Does adding a psychosocial cessation intervention to an existing life-skills and tobacco-prevention program influence the use of tobacco and supari among secondary school students? Findings from a quasi-experimental trial in Mumbai, India. Tob Prev Cessat. 2019;5:45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.18332/tpc/113355\u003c/span\u003e\u003cspan address=\"10.18332/tpc/113355\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHawsawi A. Tobacco Use, Second Hand Smoke Exposure and Associated Factors among Saudi Arabian Middle School Students: A Cross-Sectional Study. \u003cem\u003eDr.H.Sc.\u003c/em\u003e Ann Arbor: Indiana State University; 2020.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBandura A. Social cognitive theory: An agentic perspective. Asian J Soc Psychol. 1999;2:21\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLund L, Bast LS, Rub\u0026aelig;k M, Andersen S. Exploring factors associated with smokeless tobacco use among young people: A systematic scoping review. Drug Alcohol Depend. 2022;240:109627. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.drugalcdep.2022.109627\u003c/span\u003e\u003cspan address=\"10.1016/j.drugalcdep.2022.109627\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMall ASK, Bhagyalaxmi A. An informal school-based, peer-led intervention for prevention of tobacco consumption in adolescence: A cluster randomized trial in rural Gandhinagar. Indian J Community Med. 2017;42:143\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4103/ijcm.IJCM_25_16\u003c/span\u003e\u003cspan address=\"10.4103/ijcm.IJCM_25_16\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFamily Health Division. National adolescent health and development strategy. In. Nepal: Department of Health Services, Ministry of Health, His Majesty's Government of Nepal; 2000. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://mohp.gov.np/downloads/Adolescent%20Health%20Strategy.pdf\u003c/span\u003e\u003cspan address=\"https://mohp.gov.np/downloads/Adolescent%20Health%20Strategy.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePeace Corps Information Collection and Exchange, United States Agency International Development. Life skills and leadership manual. In. Washington, DC: Peace Corps Information Collection and Exchange and United States Agency International Development; n.d. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://files.peacecorps.gov/library/M0098.pdf\u003c/span\u003e\u003cspan address=\"https://files.peacecorps.gov/library/M0098.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTeles LMR, de Oliveira AS, Campos FC, Lima TM, da Costa CC, Gomes LFS, Oria MOB. Damasceno AKdC: Development and validating an educational booklet for childbirth companions. Rev Esc Enferm USP. 2014;48(6):977\u0026ndash;84. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/S0080-623420140000700003\u003c/span\u003e\u003cspan address=\"10.1590/S0080-623420140000700003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adolescent, Behavior, Health education intervention, Protection motivation theory, School, smokeless tobacco, Students","lastPublishedDoi":"10.21203/rs.3.rs-6891275/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6891275/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eSmokeless tobacco is a kind of tobacco that is chewed or sniffed; e.g., \u003cem\u003ekhaini\u003c/em\u003e, \u003cem\u003egutkha\u003c/em\u003e, \u003cem\u003epaan-parag\u003c/em\u003e, and \u003cem\u003epaan\u003c/em\u003e. It is harmful to health, but over 300\u0026nbsp;million people in the world consume it. Its consumption among the adolescent students of Nepal is increasing. It needs to develop a theory-based health education intervention to prevent students from consuming smokeless tobacco.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e\u003cp\u003e Four focus group discussions were conducted among the students of Class 9 by following the guidelines based on constructs of protection motivation theory. Based on the rigorous review of literature and feedback from the supervisor, a module of theory-based health education intervention was drafted. After that, a pilot test of the intervention was conducted among the students of Class 9. Data from 16 students who participated in the pilot test was analyzed to identify reliability and face validity of the intervention. The content validity of the intervention was assured through feedback from the supervisor and literature. After that, the final draft of the theory-based health education intervention was prepared.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eWe found students who participated in focus group discussions had insufficient knowledge regarding smokeless tobacco and its harmful effects. They had many misconceptions related to smokeless tobacco consumption. They accepted the need for skills to prevent themselves from smokeless tobacco consumption. They voiced that the strict rules should be implemented in the school premises to control tobacco consumption. Including the information related to these findings, the protection motivation theory-based health education intervention was developed. Cronbach\u0026rsquo;s alpha values of each objective of each session were more than .8. More than 80% of participants of the pilot test agreed with the effectiveness and appropriateness of the components of the intervention.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eWe developed a highly reliable and valid protection motivation theory-based health education intervention. Its proper implementation might raise knowledge of students regarding smokeless tobacco and its effects and enhance their skills to prevent its consumption.\u003c/p\u003e","manuscriptTitle":"Developing a Theory-based Health Education Intervention to Prevent Adolescent Students from Smokeless Tobacco Consumption","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-15 16:35:50","doi":"10.21203/rs.3.rs-6891275/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-05T15:12:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-24T09:37:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-15T11:32:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"115052597876851196911588399288403492497","date":"2025-07-14T02:08:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"237989363839591266735908054955675862376","date":"2025-07-13T09:35:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"258151306820456839244548190739321570149","date":"2025-07-12T06:43:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-11T16:37:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-11T16:06:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-03T05:40:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-03T01:37:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-07-03T01:34:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"963f710b-715b-416c-bd10-40e5ce48aa97","owner":[],"postedDate":"July 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-29T16:06:24+00:00","versionOfRecord":{"articleIdentity":"rs-6891275","link":"https://doi.org/10.1186/s12889-025-26000-0","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-12-23 15:58:18","publishedOnDateReadable":"December 23rd, 2025"},"versionCreatedAt":"2025-07-15 16:35:50","video":"","vorDoi":"10.1186/s12889-025-26000-0","vorDoiUrl":"https://doi.org/10.1186/s12889-025-26000-0","workflowStages":[]},"version":"v1","identity":"rs-6891275","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6891275","identity":"rs-6891275","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}