The findings are organised by the three functions for process evaluations: implementation, context, and mechanisms of impact.25 Where headteachers and teachers offered views, both perspectives are presented. If only teachers or headteachers spoke of an issue, this is evident because only those accounts are included.
Implementation -What was delivered (quantity)
Ninety-eight per cent of the SFI components were delivered across the six schools (see Table 1). The negotiation skills sessions (avoiding exposure to SHS, difficulty of changing smoker’s behaviours) were not delivered in one school respectively
Teachers described delivering the SFI to between 40 and 60 children. Approximately half had run the two sessions after the timetabled classes had ended. Others had run the SFI sessions instead of timetabled classes, specifically mathematics or science. One headteacher was willing to cancel scheduled classes to deliver the SFI because the school was committed to this type of project.
The length of the two sessions (designed to be 45 minutes) ranged from 40 to 100 minutes. Most teachers commented that 45 minutes were insufficient and that between five and 60 additional minutes were needed to complete activities and encourage discussion, particularly in larger classes. A few stated that 45 minutes was acceptable if the session was well planned, any longer the children would get bored.
The four refresher sessions had been delivered at a variety of times in the school day: in the first class or last class of the day, after finishing class tests or after class. Teachers reported that these sessions typically lasted 10–25 minutes. Half said that 15 minutes was sufficient, whilst others needed five more minutes.
In discussing the activities within the two SFI sessions (1. flipchart, role play; 2. story book, word search and quiz) the teachers explained how they had tailored three activities to best suit their class. In selecting children for the role play, most teachers had asked for volunteers; however, a few had selected children either because they were perceived to be similar to the characters in the story or because they were confident performers (Fig. 2, quote 2.1). Three teachers described how some children, particularly girls, were shy at first about the prospect of acting. For the story book activity, some teachers had read the story to the children, some asked for volunteers or selected children to read to the class whilst others gave the book for the children to read themselves. Finally, two methods of organising the quiz activity were evident; several teachers read out the questions to the whole class and the children raised their hands to answer; others divided the class to compete as quiz teams.
A range of activities had been covered within the refresher sessions: collecting in the promise forms, reminding children of what they had learnt about SHS, asking them to share what was happening at home with their father’s smoking, and providing further encouragement on negotiating with parents (Fig. 2, quote 2.2).
Implementation - what is delivered (quality)
The mean fidelity score across the six schools was 36.83 (SD 3.49, range 31 to 41) of a maximum possible score of 44, indicating reasonable to good delivery of the SFI (see Table 1). The components that were less well delivered, across all schools, related to teaching negotiation skills and creating a SFH (mean scores all below 1.5 of maximum 2). More didactic components e.g. explaining about SHS were typically well delivered (mean scores all above 1.5). Notably, all of components on day 2 (storybook, word search, quiz, promise forms) were correctly delivered (mean scores all 2).
Consistent with the fidelity data, teachers were unanimously positive in their overall assessment of the SFI delivery. They were asked to reflect on how well the different activities had gone, and to propose improvements to their content and delivery. They all liked the pictures in the flipchart which they believed had held the children’s attention, helped them to understand the messages and to develop confidence to speak with their parents about having a SFH (Fig. 2, quote 2.3). To improve the activity, two teachers and three headteachers suggested replacing the flipchart with a more modern multimedia presentation.
The majority view was that the other activities in the two sessions did not need improvement, as they were informative, and the children had enjoyed them, as evidenced by their enthusiastic participation. Some teachers suggested including more harmful effects of SHS within the role play and story, as well as adding more words into the word search (perhaps in English) and more questions into the quiz. These ideas were all seen to provide children with even more information about SHS.
The general perception was that the children had understood the purpose of the promise form and were very motivated to take it home. One teacher had encouraged the children to talk to their parents about Bijoy’s story when discussing the promise form. Most teachers said that the children had brought back the promise forms signed by their fathers and had reported no problems in discussing it with their parents. Some described the children’s accounts of using the promise form: some fathers had been reluctant at first to put up the SFH signs then did so later; parents had learnt of the risks of SHS through conversation with their child, and some parents had tried to create a SFH (Fig. 2, quote 2.4). There were no suggestions on how to improve the promise form.
Implementation - how is delivery achieved (training and resources)
All teachers had received one day of training on the SFI. Overall, this training was well received. Some said that they had already known about SHS, but the training had provided them with more facts as well as with ideas on how to share this knowledge with the children, their own families and friends. For others, the training provided them with new knowledge about SHS and achieving a SFH (Fig. 2, quote 2.5). Two teachers offered thoughts on the most useful component of the training, namely the opportunity to share and discuss their ideas for delivering the SFI with other teachers and the written materials on SHS.
A few suggestions were offered to improve the training. First, to provide it to all teachers to develop capacity for delivering the programme within the school. The second idea was to deliver the training over two or three days to have more time to cover the material and for “hands on” training. It also was suggested to have a refresher session every few months to maintain the teachers’ enthusiasm, remind the children not to smoke themselves and to monitor the impact of the SFI. Finally, a teacher and a headteacher (from the same school) suggested training two children from each class to be “co-warriors” who would support their classmates with the SFI (Fig. 2, quote 2.6)
Context - factors which affect implementation and outcomes
An important contextual factor affecting delivery of the SFI was timing within the school year. One teacher suggested that the SFI should be delivered to other year classes or scheduled in December to avoid exams. Four teachers spoke of the difficulty for the children to find time to complete the symptom diary (not part of SFI, instead a data collection tool for the evaluation) because of their intense studies leading up to Class 5 exams. One said that because of this pressure many children had lost their diary and stickers; adding that it was difficult to keep track of the children and their diaries once they had moved to Class 6.
Context was seen as particularly important in achieving sustainable delivery of the SFI. Several teachers and two headteachers spoke of the importance of embedding the SFI into the school curriculum so that it becomes compulsory to teach. This was based on a view that it would reach more children, ensure it becomes routine for the teachers and in studying this topic for exams would ensure that the children and parents learnt important messages about SFH (Fig. 2, quote 2.7). An alternative perspective was offered by one headteacher – namely, that the SFI should not be included in the curriculum and should stay as a standalone programme delivered outside of class time. This was because there was already sufficient teaching on smoking in the curriculum, and additional sessions distracted the children from their regular study (Fig. 2, quote 2.8).
In discussing where in the curriculum the SFI should be taught, most teachers and headteachers suggested it would sit best in the health-related chapter of the science text book. Other suggestions were to include it: in the social science text book where the risks of tobacco and addiction were taught, within teaching about the environment, in Islamic studies, as part of listening and reading in English or Bangla lessons, or in a subject recently introduced called ‘Work and Life Oriented Education’. One headteacher declared that where the SFI best fits in the syllabus would depend on whether it was being taught from the perspective of morals or health. A few teachers spoke of the difference of the SFI to other lessons on smoking, particularly that it was longer and more detailed (Fig. 2, quote 2.9). For one, this was a barrier to including it within the curriculum.
Finally, a few teachers, and most of the headteachers, observed that the Government of Bangladesh would need to take the decision for the SFI to be included in the curriculum. One headteacher saw that as difficult to achieve because the Government would be concerned about disrupting the schedule of regular classes. Other participants were encouraged that the Government had updated the curriculum to include additional topics, for example HIV; and that a disaster management programme had been integrated into the social science curriculum, due to considerable work by a Non-Governmental Organisation (NGO).
Also viewed, by all headteachers, as important to delivery and sustainability of SFI was schools working in partnership with NGOs. The key facilitators to successful partnership working were seen to be cooperation, not interrupting the everyday running of the school, focusing on benefiting the children and working together on a regular basis. A few headteachers suggested setting up a team to include 2–3 teachers and a member of the school committee from each local school, to work with NGO representatives (Fig. 2, quote 2.10). Half of the headteachers saw no barriers to partnership working. The others identified funding, specifically that NGOs have limited funding and cannot work with every school; and that teachers cannot miss classes to attend the aforementioned team meetings.
Mechanisms of impact - participant responses to, interactions with the intervention
All teachers and headteachers spoke positively about the SFI and its constituent activities. The headteachers commented that their teachers had been interested, enthusiastic and committed to delivering it well even when this had required them to teach extra classes to catch up on routine teaching that was missed due to accommodating the SFI. Participants identified benefits to themselves, the children and more widely for society. In terms of benefits to themselves, several teachers commented on how much they had enjoyed the experience of delivering the SFI and that it had raised their own awareness of the risks of SHS.
All of the teachers and headteachers talked about how much the children had enjoyed taking part in all of the SFI activities, and that SFI had taught them important messages about the risks of smoking and SHS at an appropriate “impressionable” (02–02, Headteacher) age to learn this. The flip chart and role play activities were considered by the majority of teachers to be the activities that the children engaged with most enthusiastically (Fig. 2, quote 2.11).
Mechanisms of impact – mediators
In reflecting on the changes that they observed in the children, teachers all mentioned an increase in their knowledge about SHS and SFH. This was seen to be very important in creating a generation who know the risks of smoking, to tackle the widespread problem of smoking in Bangladesh. They described how children engaged with the messages in the flip chart activity (evidenced by how many questions they asked). It was suggested that storytelling with lots of pictures was a good way to teach the children important SFH messages and to help them to remember these. The pictures with children in them were mentioned as particularly helpful in this, specifically the picture of Bijoy and his mother planning together to speak to his father (Fig. 2, quote 2.12). The quiz and word search were seen to have taught the children new facts about SHS, for example how much money people spend on smoking, how many people are affected by smoking, how many die from smoking, the risks of SHS and who is most vulnerable to these risks; as well as new words about SFH and their meanings.
A second change in the children, mentioned by several teachers, was learning negotiation skills and developing confidence in using these skills with their family. This was achieved through the role play activity as well as seeing Bijoy successfully achieve a SFH. Two teachers suggested that children had become key agents of change within the family home and so could persuade their parents not to smoke at home, and eventually to not smoke at all (Fig. 2, quote 2.13).
Mechanisms of impact – unanticipated pathways and consequences
Two positive anticipated consequences of the SFI were reported. One teacher described how he was stopping smokers in the street to try to convince them not to smoke in public places. A headteacher spoke of how the project had resulted in a member of staff no longer smoking on the school premises (Fig. 2, quote 2.14).