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FIELD METHODS FOR COMMUNITY HEALTH REPORT 2003 1 USE OF AND ATTITUDES REGARDING TOBACCO AMONG YOUTH IN THE MONTEVERDE ZONE, COSTA RICA 2003 Stephanie Potts Rebecca Stepan Kelly Yarzab Field Methods for Community Health Monteverde Institute June 21 to August 3, 2003
FIELD METHODS FOR COMMUNITY HEALTH REPORT 2003 2 Research Team Background Primary Investigators Stephanie Potts Undergraduate Student at the University of Pennsylvania Department of Anthropology and Environmental Studies in Philadelphia, Pennsylvania, Intermediate Spanish Speaker Rebecca Stepan Graduate Student a t the University of Minnesota School of Public Health Division of Nutritional Epidemiology in Minneapolis, Minnesota, Intermediate Spanish Speaker Kelly Yarzab Undergraduate Student at the University of South Florida Department of Anthropology in Tampa, Florida, Beginning Spanish Speaker Advisors Lynn M. Morgan, PhD (Medical Anthropology), MA (Anthropology), Professor at Mount Holyoke College Department of Sociology and Anthropology Nadine R. Peacock PhD (Biological Anthropology), MA (Biological Anthro pology), Professor at University of Illinois Chicago School of Public Health Sophia Klempner MPH, Academic Director at the Monteverde Institute Local Resource People Anbal Torres Executive Assistant, Cmara de Turismo de Monteverde (CETAM) and Resident of Santa Elena Gaudy Picado Resident of Santa Elena
FIELD METHODS FOR COMMUNITY HEALTH REPORT 2003 3 Introduction According to the World Health Organization, tobacco use is a growing concern worldwide especially among youth and especially in developing countries. Community members in Santa Elena and surrounding areas in the Monteverde Zone have indicated to the Monteverde Institute that they are concerned about the increasing use of tobacco by young people. The Monteverde Institute believes this explor atory research that utilizes extensive observations, participant observations, structured and unstructured interviews, and focus groups has the potential to inform prevention and education programming in the area. Given the theoretical framework of the st udy (see Appendix A), future longitudinal research can easily be done by building on this. Focus groups generate a rich understanding of experiences and beliefs. This method is useful for exploration and discovery when little is known about thoughts and attitudes. Focus groups also provide context and depth by creating a process of sharing. In addition, this method identifies problems because of its emphasis on discovery. Further education planning and program implementation for a longer research proje ct need this type of preliminary research. Purpose The Monteverde Institute has indicated that the community has several questions regarding youth tobacco use that are still unknown including the following: 1. How do young people acquire cigarettes? 2. With wh om do young people first smoke, in what social context and/or what emotional state/s? 3. What are the reasons young people continue to smoke to look cool, to fit in, to relax? 4. The contexts, besides bars and discos, in which young people smoke. 5. Who young peo ple listen to for health related advice how much sway to parents still have in this rapidly changing society/culture? 6. What influence does tourism have on smoking habits do people in jobs that bring them in direct contact with tourists tend to be more i nfluenced or less? In what ways has tourism shaped the availability of the product and/or the visibility of smoking? Our methods and project design seek to address the following objectives: To explore and gain information about the context in which tob acco is used. To explore youth attitudes and beliefs regarding tobacco use. Reasons youth are beginning to and continuing to use tobacco.
FIELD METHODS FOR COMMUNITY HEALTH REPORT 2003 4 Methods This study was a preliminary assessment of the attitudes and patterns of tobacco use among youth. The data was meant to be exploratory and to gain rich insights from the youth themselves in the Monteverde area. This project was based on Rapid Assessment Procedures (RAP). Our investigation consisted of a literature review and extensive data collection in the form of observations, structured and unstructured interviews, and a focus group over a three week period. ansition from primary to secondary school is a time when the initiation of tobacco use tends to occur. We therefore chose youth in the 7 th to 9 th levels of the secondary schools as our preferred population. Data collection methods included observations participant observations, unstructured interviews, and four focus groups, two each of boys and girls in order to complete the triangulation component of RAP. Using several different resources for data collection increased validation of the qualitative d ata. Our data was analyzed qualitatively using expanded field notes from the observations and focus groups. The local resource people have also indicated that a phone call to parents would be the best method to obtain consent for the children to particip ate in the focus group. We also prepared a consent form to give the youth at the start of the focus groups. The participants were asked for permission to have the focus group taped and transcribed to facilitate analysis; however we were denied permission to tape record. Focus Group : We recruited 9 participants ages 14 27 to participate in a focus group. Youth were recruited with help from local advisors. Group leaders were contacted first and given information about our project as well as a sign up she et. Local community members were used to conduct the focus groups for their fluency in Spanish and knowledge of regional variation in dialect. Observations : Observations were done at local discotheques in addition to observations at local businesses and restaurants in the community. observations were ensured through the use of alpha numeric codes and other identifying information was masked or withheld. Comm ents will not be traced back to an individual in the results. All documents that include the names of the participants from the consent forms were only seen by faculty advisors and researchers. These forms are kept secure at the Monteverde Institute. Th e participants were informed of this procedure at the time of the interview or focus group. Results The results we compiled from our focus group consisting of 9 girls ages 14 27 are summarized in Table 1. The results from our observations and interviews at 26 locations in the area between July 3 rd and July 30 th are summarized in Table 2.
FIELD METHODS FOR COMMUNITY HEALTH REPORT 2003 52 Table 1. Summary of Themes Attained from Focus Group Table 2. Summary of Themes Attained from Observations and Interviews Perceptions of Tobacco Perceptions Advertising Is Tobacco a Drug? Reasons to Start Smoking Reasons for Continuing Reasons for Quitting Possible Solutions People start with tobacco, and then when that stops having an effect they continue with other drugs. It is something common and cigarettes have the best ads on TV with horses and cute guys, but they always say at the end that smoking is hazardous to yo ur health, but you get confused because the ads are so nice. It is not a drug because it does not give a lot of health problems. There are no drugs, just bad habits. It is a drug because it affects people. The first things you think of when you think of drugs are cocaine and marijuana; you do not think of tobacco and it is because of lack of education. [Cigarettes] are not restricted. Family Problems. Form of escapism. Peer Pressure. To call attention To try it. So people will notice you. Due to the environment such as bars. They are not educated. The habit. They like it. They have done it since they were young. Some say they can not stop. Information from TV campaigns. Information from brochures. Information from film. There is a need for something stronger and more dynamic. Education other forms of strong education; dynamic and fun classes; different people teaching who have experience with youth; testimonials. Structural need a healthy place for youth; an alternativ e to bars; there is not a park or place for youth. Who is buying and using cigarettes? What brands are being purchased? Where are cigarettes being sold and used? When are cigarettes being used? Why do stores sell and advertise for cigarettes? How are cigarettes made available to minors? Mostly men and tourists are buying, all using. Ages 18 40 buying, younger also using. Purchased individually, not in groups. Derby by locals. Marlboro by tourists. 20 pack by men, 10 pack by women. Mini supers, pulperas, supermarket, restaurants, gas station. Bars and discos. Large cases of individual packs behind the counter and registers. Some cartons and packs amongst the candy and snacks. Late afternoon and evening. Before and after work. At bars and discos along with drinking. To attract tourists who then buy other products. So they do not lose business to vendors who do sell cigarettes. Adults purchase cigarettes for minors. Some youth steal from adults and parents. Go to store and tell cashier they are for a parent or adult. Cigarettes are given to people at bars and discos. If they look older than 18 they might not be carded at a store.
FIELD METHODS FOR COMMUNITY HEALTH REPORT 2003 1 1 Conclusions After analyzing the data collected from the focus group we found four main themes. Participants have good knowledge of the health and beauty effects of smoking; however, they did not consider cigarettes a drug. This could be due to insufficient drug educ ation programs in schools. Many of them had family members and friends who smoke, which makes it hard to resist temptation or give up the habit. Participants stress that education should begin in the home. They also believe that the adults should set an example for the youth. Participants want a drug and alcohol free place where they can socialize and have fun. Limitations of Study One limitation was not having a second focus group of boys. Also, all of the group members were not fluent in Spanish ; therefore it was difficult to conduct the interviews and the focus group. Recommendations for Future Studies Focus groups conducted with boys as well as more with girls in several age groups Data collection to set up a longitudinal study within an ecolo gical model as the theoretical framework. This type of study can monitor individual use patterns and attitudes over time. Some of the variables may include the following: Environmental influences such as family or friend use of cigarettes Tax increases Laws for stricter carding Laws for cigarette placement (i.e. behind cashier vs. among candy) The effect of an educational program on experimental and control groups of students Acknowledgements We would like to acknowledge Lynn Morgan and Nadine Peacock for advising us on our project. We would also like to acknowledge Gaudy Picado for conducting our focus group with the girls as well as Dulce Wilson and Sarah Burbank for helping us to recruit the girls for the focus group, Anbal Torres f or going to the bar observations with us and for giving us ideas and information about the Monteverde area, and Sophia Klempner for taking notes during the focus group, helping to recruit the girls for the focus group and translating our data. Finally, w e would like to acknowledge Dr. Nancy Romero Daza for translations and revisions.
FIELD METHODS FOR COMMUNITY HEALTH REPORT 2003 2 2 References Interviews Meeting with members of Instituto para las Adicciones Farmaco dependentes y Alcoholismo (IAFA) in San Jos, Costa Rica. Monday, June 23 rd at 1:00 p.m First meeting with local resource person, Anbal Torres, Executive Assistant Cmara de Turismo de Monteverde (CETAM), Member Monteverde Municipality, and Monteverde resident. Wednesday, June 25 th at 11:00 a.m. Follow up meeting with local resource per son Anbal Torres for project planning and development, Wednesday, July 2 nd at 11:00 a.m. Literature Review Bejardo Orozco, Julio and Federico Ugalde Montero. Instituto sobre Alcoholismo y Farmaco dependencia. rea Desarrollo Institucional. Proceso de Investigacion. Consumo de Drogas en Costa Rica: resultados de la encuesta nacional del 2000 2001 Section 3.2, pp. 38 41. Instituto Sobre Alcoholismo y Frmaco dependencia (IAFA). Qu son las drogas? Generalidades Efectos. Published by the Proceso de Comunicacin IAFA, 2002. La Encuesta Mundial sobre Tabaco en Jvenes (GYTS) Costa Rica, 2002. http://www.cdc.gov/tobacco/global/GYTS/questionnaire/SpanishQuestionnaire.ht m Pan American Health Organization. (2003). http:www.paho.org Salud o Tabaco San Jos, Costa Rica. Number 12. April, 2003. Published by the Asociacion Costarricense Salud Publica (ACOSAP). Spradley, Hames P. (1979). the Ethnographic Interview Fort Worth: Harcourt Brace Jovanovich College Publishers. Scrimshaw, Susan C. M. and Elena Hurtado. (1987). Rapid Assessment Procedures for Nutrition and Primary Health Care: Anthropological Approaches to Improving Programme Effectiveness Published jointly by the UCLA Latin American Center, the United Nations University (Tokyo) and UNICEF. World Health Organization. (2003). Tobacco Retrieved from the World Wide Web June, 2003. http:www.who.org
FIELD METHODS FOR COMMUNITY HEALTH REPORT 2003 3 3 Appendix A: Theoretical Framework Our approach to exploring tobacco use and attitudes regarding tobacco from youth in the Monteverde Zone will utilize the Ecological Model. This theoretical model will help us to learn about perceptions of tobacco use as they relate to interpersonal, institutional, community, and public policy. In addition to the time constraints and feasibility of this study, we have learned that no previous work on tobacco use and perceptions has been done in this area. We have decided that within the ecological fr amework which is the basis for a more extensive research study our short project will focus on several intrapersonal, interpersonal, and community factors. Intraper sonal Knowledge Personal beliefs/harmful Self esteem Self efficacy Interpersonal Social norms Peer pressure Role modeling Institutional Class schedule School structure Health class Community Local availability Acceptability Tourists Public Policy Business/restaurant revenue from tobacco companies Taxes Health Behavior: Youth Tobacco Use
FIELD METHODS FOR COMMUNITY HEALTH REPORT 2003 4 4 Appendix B: Focus Group Questions Introduction: Hello and welcome! We are students from the M onteverde Institute participating in a health attitudes about smoking. We think that having relaxed, friendly conversations with groups like this will help us to understand what young people really think. We brought pizza and drinks for everyone, so we will now take a minute to get some refreshments. Then you can come and sit down where you see your name tent (or name tag). First, we want to thank you for joining this group today. Your comments and opinions during please be sure to respect each other and give everyone a chance to talk. There are no correct or incorrect answers to the questions, and remember that you do not need to answer or talk about something if you do not want to. We have copies of a consent form we will read out loud. Each of you will have a copy for yourself as well to read and sign. Opening Question: Everybody will be looking at pictures of people from magazines. Please look at these people and pick out which people you think look healthy and unhealthy. Everyone will tell an example of both and explain why this picture shows either a healthy or unhealthy person. Discussion : Participants discuss why the people they drew are healthy and what it means to be healthy. Would you consider this person to be a r ole model? Who are your role models and who do you want to be like? Objective concepts of health, health knowledge, and ideal role models. Key Questions with subset pr obes: Question 1. We would like to know more about what everyone thinks about tobacco, and about people who smoke. First, what are some characteristics of people who smoke? Probes : Physical characteristics? Age? Men or women? Social characteristics? Who are their friends? Are people who smoke tourists, Ticos, or both? Question 2. Probes : Are the reasons different for youth and adults? If so, how are they different? Once someone starts, are there other reasons why they keep smoking? Question 3 wi th other people. Probes : On social status? On health? On popularity? On relationship with thin, as well as negatives like yellow teeth, bad breath)
FIELD METHODS FOR COMMUNITY HEALTH REPORT 2003 5 5 Probes : Is it socially accepta ble to smoke in Monteverde? For girls? For boys? For young people? Probes : Is it easy for people to stop smoking once they start? Why might someone want to stop smoking? Question 4. es pecially how they get cigarettes, where they smoke, and whom they smoke with. Probes : Buy cigarettes themselves? Get them from older youth or adults? Do they smoke openly or in secret? Question 5 Some p eople think about tobacco as a drug that has dangers like other drugs, and others think of it as a normal recreational activity. What do you think? Is tobacco a drug? Why or why not? Probes : Compare tobacco to other things that are labeled as drugs. (Lega l vs. illegal; danger; addictiveness). Question 6 : What kind of education about tobacco and smoking do young people get in schools? Who are the people who provide this information? Probe : Are these the same people who teach generally about health? Fin al Question, time to refocus, let the participants know we are almost finished with the focus group. Question 7 : What, if anything, do you want to know about smoking? Do you want more education about smoking? Probes : Who would you like to give you information about smoking, for example, your parents, teachers, the clinic nurse, or an older student with experience and knowledge of smoking? TV or radio?
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Actitudes y uso del tabaco entre la juventud en la Zona de Monteverde, Costa Rica, 2003
Use of and attitudes regarding tobacco among youth in the Monteverde Zone, Costa Rica 2003
Project addressing youth attitudes and beliefs regarding tobacco use, where young people get information on the effects of cigarette smoking, what groups of people are most likely to begin smoking, and who and what influences their choice to smoke.
Proyecto de actitudes y creencias de los jvenes sobre el uso del tabaco, donde los jvenes obtienen informacin sobre los efectos del cigarrillo, que grupos de personas tienen ms probabilidades de comenzar a fumar, y quin y qu influye en su eleccin de fumar.
Public health--Costa Rica--Puntarenas--Monteverde Zone
Teenagers--Tobacco use--Costa Rica--Puntarenas--Monteverde Zone
Community Health 2003
Health seeking behavior
t Community Health