This study was a quazi-experimental field study with control group design conducted in the coffee shops of Hashtrud (intervention group) and Qarah-Aghaj (control group) counties in Eastern Azerbaijan province, Iran. The study was conducted in two phases. In the first phase (pre-test), the frequency and the determinants of hookah smoking behavior was investigated based on Socio-ecological model (SEM) to find the significant predictors of the behavior among the participants. Based on the results found at the pre-test phase, a health promotion intervention program was designed and implemented in Hashtrud County, as the setting of intervention. The underlying idea is that interventions should include multilevel strategies focusing on individual behavior, social and environmental levels[23]. Following aspects were emphasized during intervention group: individual (education based on telegram), social approaches (create social network, social support of peers and reward to decrease hookah use) and environmental levels (changes in coffees).
Instrumentation
The instruments used in the present study included a demographic data form, three items about the frequency of hookah smoking, hookah use-related individual and social level factors questionnaires and an environmental level factors checklist. The questionnaires applied to assess the individual level factors and perceived rewards(from the social level factors)were developed and validated in a previous study [24].
To assess validity of the researcher-made instruments, a panel of 10 scholars (in the fields of health education and behavior, sociology, psychology and epidemiology) reviewed and assessed the items, orally, and evaluated the appropriateness and relevance of the items to the participants. They confirmed the items to be representative of the constructs in order to confirm content validity of the instruments. We used the experts’ feedback on the instruments to revise and modify the items. Content Validity Ratio (CVR) with the feature of "necessity" and Content Validity Index (CVI) with two features of "relevance" and "sufficiency of each construct" were measured. In order to examine the utility of the scales and to identify the problems/benefits associated with the design, the instruments were pilot-tested by a sample of 30 hookah users not included in the final study. We used the data to estimate the internal consistency of the scales using Cronbach’s Alpha coefficient. Following consultation with the multidisciplinary team, the first draft was prepared.
The demographic data form included age, level of education, marital status, employment status and level of income.
The frequency of smoking was investigated applying three researcher-made self-report items. The items were as follow: “In previous 3 months, how many times per week have you smoked hookah?”, “How long is the duration of your hookah smoking per serving?” and “How many cigarettes have you smoked in previous seven days?” The CVI and CVR scores for the items of frequency of smoking were 91.0 and 86.6, respectively.
The scales of individual level factors included perceived sensitivity (5 items) and perceived severity (8 items). Examples of the items for perceived susceptibility and severity were "Using hookah will increase my chance for getting lung cancer ", and “Smoking hookah will reduce my chance for getting a suitable job", respectively. Perceived internal and external rewards acquired from hookah use were also investigated applying a nine-item scale. One item, as an example, was "By smoking hookah, I feel that I am grown-up and feel like a man". The triple scales were rated based on a five-point Likert-type scaling (ranging from 1 = totally disagree to 5 = totally agree). The scores of the scales were then summed to acquire a total score. The maximum total score for perceived susceptibility, severity and rewards were 25, 40, and 45, respectively. The higher the scores in the triple scales indicated the higher levels of perceived susceptibility, severity and internal and external rewards among the individuals to smoke hookah. All scales are developed and validated in a previous study in Iran {Sabzmakan, 2018 #1} {Ghasemi, 2015 #45;Sabzmakan, 2018 #152}.
Perceived social support questionnaire including 14 items was applied to assess the social level factors. Examples of the subjects presented in the items included “encouraged you not to go to the coffee shops to smoke hookah” and “encouraged you not to smoke hookah”. The response format was based on a 5-point Likert-type scale (from never [1] to always [5]). The total score was ranged from 14 to 70. The higher the score, the higher the level of social support was perceived by the individuals to smoke hookah. CVI and CVR values for the scale were 90.64 and 74.42, respectively, and the alpha Cronbach's coefficient was 0.72.
A researcher-made 11-item environmental checklist was used to assess the environmental level factors. A dichotomous Yes/No scale was considered as response format. An example of the items in the checklist was "Is there any game/ entertainment tool available in the coffee shop?"
Sampling and data collection
In order to conduct the study, Hashtrud County was considered as the setting to conduct the intervention. All coffee shops in Hashtrud (11 cases as intervention group) and Qarah-Aghaj (center of Charuymaq County) (7 cases as control group) were selected as the study centers. As primary coordination, the first researcher personally went to the coffee shops and explained to the administrators about the purpose of study and the way it would be conducted at the coffee shops. Then, the purpose of the study was explained to the hookah smokers in the coffee shops and they were invited to participate in the study. Informed consent was obtained from both the administrators and the hookah smokers accepted to participate in the study and all signed consent forms. They were also assured on the confidentiality of their information. Along with data collection, applying the SEM-based questionnaire, the environmental checklist was also filled out based on the observations conducted by the second author. In each County, 133 hookah smokers at the coffee shops were included in the study. The flowchart of the study is illustrated in Fig. 1.
The intervention was performed in all Hashtrud coffee shops during eight weeks from January to March, 2017. Inclusion criteria were willingness to quit hookah smoking in the following 6 months, willingness not to refer to the usual coffee shop to smoke hookah in the following 6 months, older than 15 and younger than 35, daily using of Telegram virtual network, and having at least one year of hookah smoking history. Exclusion criteria were using drugs and narcotics other than cigarettes and the tobacco used in hookah, illiteracy, having plans to quit hookah smoking and suffering from psychological disorders or mental problems such as depression.
Interventional Program
Based on the pre-test data analyses, the problems and weak points at the individual, environmental and social level factors related to hookah smoking were identified. Therefore, the interventional program was designed and implemented as follows: A virtual group named "No to hookah smoking" was established on the Telegram application to train the participants in the intervention group, informally. In order to promote their level of perceived sensitivity and severity, the participants were encouraged to share the group members with text messages, pictures and short videos regarding the outcomes of hookah smoking, health disadvantages of the behavior, the mechanisms via hookah smoking may damage human health, the ways and benefits of quitting hookah use and how to resolve the obstacles, how to alleviate and control the temptation to smoke hookah, and alternatives for hookah smoking in the coffee shops. We initiated a group discussion to talk about the contents. To promote internal and external rewards among the participants, potential alternative rewards that may be achieved by reducing or quitting hookah use were discussed among the group members. The group members were socially supported by the managers of the group and the peers. The members received a variety of informational, emotional, and instrumental support. Group members rewarded each other by verbal encouragements as well as low internet service charges.
The resources and costs needed to implement the program included the coffee shops, the cost of internet service provision and the time required to send messages. The key strategies applied to design the program were network-based education, consciousness raising, environmental reconstruction, environmental reevaluation, role modeling, and perceived thread rising. The main processes applied to implement the program were experimental informal teaching methods (incorporating in the virtual social network and discussing the messages in the virtual group and reaching census, problem-solving discussions), discussing the early negative consequences of hookah smoking (e.g., coughs early in the mornings), and revisiting the services provided to customers in the coffee shops.
The training team at the group consisted of a public health expert and two researchers of the study (an epidemiologist and a health educationist) who managed the virtual group with 614 members. Also, 11individuals, who used to smoke hookah but have then managed to quit, were included in the group, as lay persons. They played the role of peers in the virtual group and discussed different ways of quitting hookah use with the group members.
In order to revise the services provided to customers in the coffee shops we conducted several changes. To help the participants in accessing healthy food choices in the coffee shops, the administrators were requested to have serving desserts and different kinds of drinks and healthy foods like lentil soup, omelet, ice-cream, figs and broad beans. The participants in the coffee shops were also provided with intellectual game accessories (like chess, mensch, and others) as alternative entertainment instruments. Moreover, hookah smoking-related posters and banners with specific focuses were installed in close to the coffee shops.
Two weeks after completing the implementation of program, the questionnaires were again completed by the participants in the experimental and control groups.
The protocol of the study was approved by Ethics Committee in an Iranian medical sciences university [Ethics code: IR.TBZMED.REC.1396.175].
Data analysis
SPSS version 23 was used to analyze the data. Descriptive statistics were calculated to determine mean and standard deviation in quantitative data and frequency and percentage in qualitative data. Independent t-test and Chi-square were used to compare the mean between the groups. Logistic models were used to evaluate the effect of multidimensional intervention on changes in the frequency and duration of hookah consumption by controlling for potential confounders. We used analysis of covariance test to compare the means after adjustment for the dependent variables and potential confounders.