Vera Nierkens

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Smoking in a multicultural society developing a
culturally sensitive questionnaire

• Vera Nierkens

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The Netherlands and its immigrants

• Approximately 10 of non-Western background
• Of the 16 million people living in the
  Netherlands
• 316,000 from Morocco
• 358,850 from Turkey
• 329,500 from Surinam
• Turks and Moroccans economic migrants
• Surinamese former Dutch colony

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Percentage of smokers (adults)
Men
Women
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Aim of the study

• Why this study
• To little information about smoking behaviour
  available to develop anti-smoking programs
• Aim
• To collect information about smoking and smoking
  cessation and its determinants among people aged
  35 60.

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Theoretical model
beliefs smoking cessation attitudes (advantages
and disadvantages) social influences self efficacy
contextual factors acculturation education
motivation
smo-king beha-viour
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Predisposing Factors
Motivation Factors
Ability Factors
Behavioral factors
Plans
Psychological factors
Attitude Pros Cons Rational Emotional
Performance Skills
Biological factors
Social Cultural factors
Social Influences Norms Modelling Pressure
Intention State
Behavior State
Awareness Factors
Precontemplation
Trial
Efficacy Routine Social Situational Stress
Knowledge
Contemplation
Cues to Action
Maintenance
Preparation
Risk Perception
Information Factors
Barriers
Message
The I-CHANGE Model De Vries et al., 2004 2005
Channel
Source
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Methods

• Survey
• To gain insight into the beliefs that may
  motivate smokers to quit among
• 385 Turks, 316 Moroccans and 1072 Surinamese
• Developing questionnaires and pilot testing

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Developing a questionnaire

• Eliciting salient beliefs
• Development of questionnaires
• Pilot testing of the questionnaire

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1. Eliciting salient beliefs

• Focus group interviews
• Recruitment of participants
• recruitment by key persons
• location of interviews familiar to participants
• Ethnic matching
• native language
• feel free to talk taboo
• Interpretation of qualitative results
• Appropriate theoretical background?
• classifying beliefs 97 classified

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Results of the qualitative study

• Different from Dutch
• sign of modernization for women
• offering cigarettes sign of kindness
• different social influences
• If smoking is not allowed women smoke in secret

• Similar to Dutch
• smoking
• relaxing effect
• makes feel comfortable
• increases health risks
• quitting
• makes one proud
• eating more
• retraction symptoms

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2. Development questionnaire

• Selection beliefs
• Belief formulation adaptation to preferences
• Answer format adaptation to verbal answer
• face to face interview!
• Translation
• preparatory discussion with forward translator
• afterwards discussion with forward and back
  translators
• meaning of the translations!

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3. Pilot testing

• Interview method
• fluency in Dutch
• educational level
• Final selection of the questions
• differences between smokers and non-smokers
• internal consistency
• clarity of questions (number of missing values)
• content validity
• comparability with other groups

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Results item selection (examples)

• Excluded
• If I smoke, I will not be accepted
• Social influence colleagues, children, parents
• If I quit I get a better condition
• If I smoke I forget my problems

• Included
• Do you feel comfortable (if you smoke)
• If I smoke, I will be ashamed
• II I quit would be proud
• If I quit, better for health
• Social influences family and friends

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The result

• Three questionnaires including
• questions, formulation adapted to group
• similar beliefs and some culturally specific
  beliefs
• Reliable scales for attitudes, social influences
  and self-efficacy (alpha between 0.66 0.95)
• Sufficient explained variance for Turkish and
  Moroccan men (66)

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Concluding remarks

• Combination of qualitative and quantitative
  methods
• Adapt methods use key persons
• Ethnic matching
• Be open minded
• Etic and emic beliefs
• Translation be aware of the meaning