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 Table of Contents  
Year : 2020  |  Volume : 64  |  Issue : 2  |  Page : 102-108  

Effectiveness of health education in reducing secondhand smoke exposure among pregnant women visiting the antenatal clinic in Saudi Arabia: A randomized controlled trial

1 Chair of Evidence Based Health Care and Knowledge Translation, College of Medicine; Department of Community and Family Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Community and Family Medicine, King Saud University, Riyadh, Saudi, Arabia
3 Department of Clinical, Princess Nourah Bint Abdulrahman University, College of Medicine, Riyadh, Saudi Arabia; Department of Biostatistics, Alexandria University, High Institute of Public Health, Alexandria, Egypt
4 Chair of Evidence Based Health Care and Knowledge Translation, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Submission10-Feb-2019
Date of Decision11-Jun-2019
Date of Acceptance27-Apr-2020
Date of Web Publication16-Jun-2020

Correspondence Address:
Amel A Fayed
Princess Nourah Bint Abdulrahman University, P.O. Box 84428, Riyadh

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.IJPH_63_19

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Background: Pregnant women's exposure to secondhand smoking (SHS) is associated with detrimental effects on the pregnancy outcomes. Objectives: The objective of the study was to compare the effectiveness of face-to-face counseling, based on health belief model (HBM), combined with a written educational pamphlet, and health education using written pamphlet only, in improving pregnant women's perception, behavior to avoid SHS and change in exposure to SHS. Methods: A randomized controlled trial was conducted in 2016. The intervention group received face-to-face health counseling on SHS, while the control group received only written educational pamphlets. Outcomes were the change in the perception of mother on the four constructs of the HBM and the change in mothers' behavior of avoidance of SHS exposure. Results: A total of 100 women were recruited for the study, of whom 93 (47 intervention and 46 control) women completed the study. All women identified their spouse as a source of SHS exposure. Following the intervention, the intervention group had significantly higher scores in the perception of susceptibility (21 ± 4 vs. 16 ± 7, P < 0.01) and severity (15 ± 3 vs. 12 ± 4, P < 0.01) and reduced perception scores of barriers to avoid SHS exposure (11 ± 4 vs. 9 ± 5, P = 0.03), compared to the control group. However, there was an insignificant change in the exposure to SHS after the intervention in both the groups; where 25 (53.2%) women in the intervention group and 31 (67.4%) in the control group (P = 0.16), continued to being exposed to SHS. Conclusion: Counselling of pregnant women, based on HBM, has insignificant effect in reducing their exposure to SHS; however it is effective in improving their knowledge and perception about SHS exposure.

Keywords: Counseling, healt education, pregnant women, Saudi Arabia, second hand smoke exposure

How to cite this article:
Wahabi HA, Massis A, Fayed AA, Esmaeil SA. Effectiveness of health education in reducing secondhand smoke exposure among pregnant women visiting the antenatal clinic in Saudi Arabia: A randomized controlled trial. Indian J Public Health 2020;64:102-8

How to cite this URL:
Wahabi HA, Massis A, Fayed AA, Esmaeil SA. Effectiveness of health education in reducing secondhand smoke exposure among pregnant women visiting the antenatal clinic in Saudi Arabia: A randomized controlled trial. Indian J Public Health [serial online] 2020 [cited 2021 Sep 20];64:102-8. Available from:

   Introduction Top

In utero exposure to tobacco smoke is associated with major health hazards to the fetus, newborn, and future adult, including impaired fetal growth, congenital malformations, preterm delivery, and increased perinatal mortality.[1],[2],[3] Furthermore, reports have been linked in utero exposure to tobacco smoke to many diseases that manifest in adulthood, such as obesity and hypertension.[4]

Recent studies from Saudi Arabia showed that despite the low prevalence of tobacco use among pregnant women, about 20% to 30% of them are exposed to secondhand tobacco smoke (SHS) and that their husband is the main source of SHS in the household.[5] In addition, the studies documented the adverse effects on the newborns of Saudi mothers exposed to SHS.[6]

Despite the high prevalence of SHS, the knowledge of Saudi pregnant women about the adverse effects of SHS was found to be modest,[7] which makes counseling and health education a viable intervention option to avoid SHS exposure, particularly in the absence of national programs designated to address the avoidance of SHS in the household.

Most of the interventions proposed to reduce the exposure to SHS among the mothers and children in the household were based on counseling and health education provided to the mother, father, or to both parents.[8],[9],[10] Counseling is usually tailored based on psychological theories, such as a health belief model (HBM) or the social cognitive theory.[11],[12],[13] The general objectives of counseling are to improve the knowledge of the mother about the health risks to her and the baby from SHS exposure, the benefits she can gain by avoiding exposure so that she can take action to avoid these risks.

In this context, the present trial was undertaken with the following specific objectives: To compare the effectiveness of face-to-face counseling, based on HBM, combined with the written information pamphlet, and health education using written information pamphlet only, in improving pregnant women perception of HBM construct (perceived susceptibility to disease from SHS, severity of harm from SHS, benefits from avoiding SHS, and ability to overcome barriers to avoid SHS exposure); in improving pregnant women' and husbands' behavior for avoidance of SHS; and in reducing the time of exposure to secondhand smoke among pregnant women.

   Materials and Methods Top

Study design, setting, and participants

A two-group parallel randomized controlled trial was conducted in the antenatal clinic of University Hospital in Saudi Arabia between January and May 2016. Pregnant nonsmoker women with a history of exposure to SHS, who did not exceed 25 weeks of pregnancy, were included in this study. We excluded from trial women who did not declare their smoking status, those who were illiterate, and those who declined to participate in the trial.

The study protocol and randomization procedure and interventions were explained to the eligible participants on recruitment. Each woman who agreed to participate was provided with a written informed consent form to sign before inclusion in the study. Following the recruitment, each subsequent participant, (total of 100 women), was randomized to either intervention or control group. Sequence generation was done by simple randomization. The words (control) and (intervention) were each written in 50 small opaque papers. Papers were folded and placed in an opaque bag. When a consecutive eligible participant joins the trial, a paper was drawn from the bag and the participant is assigned to either counseling group (intervention) or pamphlet only group (control). Following the randomization, each participant completed a preintervention questionnaire. Then, participants received either written information about hazards of SHS exposure (control group) or counseling in addition to the written information (intervention group). Four weeks following the interventions, participants from both the groups were invited again to complete a postintervention questionnaire. Three participants in the control group and four from the intervention group did not return for their follow-up sessions.

Blinding of participants or researchers was not applicable; however, blinding of the analyzer/evaluator was confirmed to avoid detection and reporting bias.

Sample size

The study was planned to compare two groups of pregnant women; one group would receive the counseling and the other group receiving only written information about SHS. Using a power of 80% (beta = 0.20), level of confidence of 95% (alpha = 0.05), and a minimum difference in changing the behaviors between groups to be around 30%, the minimal sample size needed to reject the null hypothesis was 40 in each group. The sample size was increased to 50 in each group to compensate for any loss of follow-up.


The counseling group was invited to attend the health counseling session done by two health educators. The educational material provided to the participants was prepared by researchers and health educators based on a review of similar published trials. The counseling was conducted verbally and face-to-face for 20 min for each study subject.

The principle of health education was based on HBM constructs. The four perceptions of the model were applied on counseling the participants, including health hazards of SHS exposure on the mother and her infant (severity) and how she is susceptible to adverse effects with even minimal exposure to SHS (susceptibility). In addition, the counseling session included dialog with the participants to clarify the positive effects (benefits) of SHS avoidance on the baby's health and to explore the obstacles (barriers) which may prevent the participant to adopt a positive action toward SHS exposure. During the counseling sessions, poster and slide shows, which included pictures of low birth-weight babies and respiratory distressed newborn, were used for demonstration. In addition, the intervention group received the same pamphlet given to the control group.

The control group was given written information only without any counseling. The pamphlet was prepared by the Tobacco Control Program, Saudi Ministry of Health.[14] It was written in simple Arabic language and was prepared for easy understanding. It provided information about the harmful contents of cigarettes and the adverse effects of SHS exposure on the mother, fetus, and the newborn.

Outcomes measures

The change in the perception of mother on the four constructs of the HBM (perceived susceptibility, severity, benefit, and barriers) and the change in her behavior of avoidance of exposure to SHS were measured by a self-administered questionnaire completed before and 4 weeks after the intervention. The questionnaire was developed to obtain the required information based on experts' opinion and literature review.[13],[15],[16] To compare the two methods of health education, the same questionnaire was used pre- and postintervention, and the change in the scores between pre-and post-intervention responses for the intervention and control groups was compared. In addition, we compared the change in pre- and postintervention scores in each group.

The questionnaire composed of the four sections: the first part provided information about sociodemographic characteristics of the mother such as age, nationality, education of mother, education of husband, working condition of the mother, and monthly household income. The second section included information of exposure to SHS status (number of days that the pregnant woman exposed to SHS, number of hours each day the pregnant women exposed to SHS, type of smoking, and number of cigarettes smoked/day at home). In the third section, women were asked questions about their health beliefs of SHS exposure that included perceived severity of the effects of SHS exposure (six questions), perceived susceptibility of the pregnant women to the adverse effects of tobacco smoke (five questions), perceived benefits of the recommended behavior of avoidance of exposure to SHS (one question), and perceived barriers avoid SHS exposure (three questions). All questions in sections three were asked using a 1–5 Likert scale. Responses to the questions were summed to create an overall score for each of the constructs of the HBM. The fourth section of the questionnaire included questions about the mother's behavior in relation to avoidance of SHS exposure, asking the smoker to quit or smoke outdoor, and the smoker's response of quitting smoking or chooses to smoke outdoors.

The effects of the intervention were measured by the change in mother's scores on the constructs of the HBM, the change in mother's and the smoker's behavior pre- and postintervention, and the change in the duration of exposure to SHS. The differences in scores and duration of exposure to SHS were compared in each group and between the intervention and control group.

Ethical consideration

Ethical approval was obtained from the Institution Review Board of King Saud University with approval letter number Ref. No. 15/0393/IRB. Written consent was signed by every participant prior to the start of the study after explaining the procedures involved. This trial was registered with the registration number ISRCTN32178828.

Data analysis

IBM SPSS Statistics for Windows, version 22 (IBM Corp., Armonk, N.Y., USA) was used for data entry andanalysis. The results were reported as percentages for categorical variables and mean and standard deviation or median and interquartile range for continuous variables after testing for the normality of their distribution. Chi-square test was used to compare categorical variables and Student's t-test or Mann–Whitney U-test was used to compare continuous variables as appropriate.

   Results Top

A total number of 253 eligible women were approached to participate during their routine antenatal care clinics, and finally, a sample of 100 women who agreed to participate were recruited, of whom 93 (47 in the intervention and 46 in the control groups) women completed the second questionnaire and included in the analysis [Figure 1].
Figure 1: CONSORT diagram describing the flow of participants through the study.

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[Table 1] shows the baseline characteristics of the intervention (counseling) and the control (pamphlet) group. The mean age of the study population was 28 years, most of them were university graduate, however, and the majority were homemakers. All women identified their spouse as the source of SHS exposure at home. The participants were exposed to SHS with a mean frequency of 2.6–2.8 days/week, with a mean duration of 2.3–2.4 h/day. The exposure to SHS showed a comparable picture between the two groups in terms of duration of exposure to SHS, daily exposure and exposure to SHS for 4 h or more daily (P > 0.05). The two groups were not significantly different, at the baseline, in their perception of the HBM constructs [Table 1].
Table 1: Comparison between intervention and control groups in baseline characteristics

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Following the intervention, the counseling group had significantly higher scores in the perception of susceptibility, severity, and benefits and significantly reduced perception scores of barriers to avoid SHS exposure, compared to the control group [Table 2]. In addition, the incremental improvement of all the constructs of the HBM was significantly more in the intervention group compared to the control group [Table 2].
Table 2: Comparison between intervention and control groups after the intervention

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The change in behavior of the mother with respect to the avoidance of exposure to SHS and the change in behavior of the husband with respect to either quitting smoking or avoid smoking in closed door are shown in [Table 3]. There are significantly more numbers of actions taken by the counseling group compared to the pamphlet only group to avoid exposure to SHS. Mothers in the intervention group were two times more likely to avoid staying with their husbands when smoking (59.6% compared to 30.4%). Moreover, husbands in the intervention group were more likely to smoke outdoor most of the time compared to the control group (42.6% and 17.4%, respectively). However, there was no significant change in the duration of exposure to SHS when the two groups were compared [Table 3].
Table 3: Comparison between intervention and control groups of change in behavior among pregnant women and their husbands to avoid exposure to secondhand smoking

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   Discussion Top

This randomized controlled trial showed that counseling based on the conceptual framework of the HBM significantly improved the knowledge of pregnant women about the health hazards of SHS exposure and subsequently increased their perception scores of SHS-related perceived susceptibility, severity, and benefits of rejecting SHS exposure scores. In addition, it showed that counseling changed the mother's and the father's behavior in relation to reducing exposure of the pregnant woman to SHS. However, the intervention did not change the duration of exposure to SHS. These results concur with previously published reports about the effectiveness of counseling, based on the HBM, for promoting preventive behavior among different at-risk groups.[11],[13],[17]

Unfortunately, very little is known about the prevalence or the determinants of exposure to SHS at home in the Saudi community, apart from a few hospital-based studies.[5-7,18] It is evident from these studies that less than 0.1% of the pregnant women were smokers[5] and up to 37% of them were living with a family member who smoked.[18] Furthermore, 24%–30% of the interviewed women declared exposure to SHS at home.[5],[18] Lower educational achievement, lower parity, and unemployment were the main sociodemographic determinants of exposure to SHS at home.[18] One study examined the pregnant Saudi women's knowledge about the adverse effects of SHS exposure to the mother, the fetus, and the child and concluded that mothers had limited knowledge about the specific harmful effects of exposure to SHS.[7]

Based on the aforementioned information, the current study was designed as the first interventional study to promote avoidance of exposure to SHS in the Saudi household.

We have chosen HBM as a theoretical framework for counseling based on many reports in the literature on its effectiveness for long- and short-term avoidance of SHS exposure in pregnant women, compared to other frameworks.[12],[13],[19],[20] The theoretical base of the HBM is drawn from the understanding that a person will take a health-related action if he/she perceives health condition as serious and can be avoided by an action on his/her part and that he/she is capable to do that action.[21]

In this study, counseling was effective in increasing the perception of the mothers about the harms which may occur to them and their unborn children and the benefits of avoiding exposures to SHS, which was reflected on their behavior of avoidance of exposure to SHS. In addition, we found that 64% of the husbands of mothers who received counseling embraced positive behavior of reducing environmental tobacco smoke, while only 32% of the husbands of mothers who received the written information without counseling did so. The findings indicate that counseling is more effective than written information. Nevertheless, one cannot ignore the fact that the intervention failed to reduce the duration the mother was exposed to SHS. The intervention may have been more effective if the father was included in the counseling sessions, as was proved by previous reports.[22] Furthermore, re-enforcement of the importance of tobacco-free environment for pregnant women, by increasing the number of counseling sessions and using mass media, may have had more impact in empowering women to avoid SHS exposure than a single counseling session.[13],[23]

This study is the first to investigate interventions to reduce SHS exposure among pregnant women in Saudi Arabia. The design of the study, as a randomized controlled trial, provides a high level of evidence on the effectiveness of counseling in this group of pregnant women. We believe that the lack of blinding of participants and personnel did not introduce bias due to the complex nature of the outcomes, which were the changes in the perceptions and beliefs of the participants.

We acknowledge that the study has some limitations, including the short period of follow-up between the intervention and the postintervention evaluation. Another limitation is the small sample size and that only one hospital was included in this study, which limit the generalization of the results.

We believe that it is important to conduct further research to evaluate the public health problem of SHS exposure in Saudi households with respect to prevalence, associated health problems among children and nonsmoker adults, and socioeconomic determinants of exposure. In addition, more studies should be conducted to investigate interventions to reduce exposure to SHS exposure, not only for pregnant women but also for other nonsmokers in the household.

The results of our study did not prove that counseling reduced the mothers' exposure to SHS, which may be due to the short duration between counseling and evaluation, or the quality and intensity of counseling; however, evidence-based guidelines recommended counseling as an effective means for the prevention of SHS exposure in the household. Implementing the World Health Organization (WHO) guidelines for the prevention of SHS exposure during pregnancy[24] will be a prudent intervention to improve health services provided to pregnant women in Saudi Arabia, which will facilitate the conduction of larger studies by trained counselors. The recommendations of WHO guidelines include the importance of assessment of tobacco use and secondhand smoke exposure in pregnancy as early as possible during pregnancy, and those health-care providers should advise pregnant women and their husbands on the interventions which reduce SHS exposure in the household.

   Conclusion Top

Counseling, based on HBM, did not show any effect in reducing pregnant women exposure to SHS; however, it is effective in improving pregnant women's knowledge and perception about the harmful effects of SHS exposure.


We would like to thank Ms. Afaf Abdulrahman for her valuable efforts to recruit the participants.

We extend our thanks to King Saud University, Deanship of Scientific Research, Research Chairs, for funding this project.

Financial support and sponsorship

This study was funded by the Deanship of Scientific Research Chairs at King Saud University.

Conflict of interest

The authors declare no conflicts of interest.

   References Top

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  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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