Self-efficacy and Avoidance Behavior from Cigarette Smoke

Exposure: A Cross Sectional Study among Mothers of Under-five

Year-old Children

Nur Lailatul Masruroh

, St. Annisa Al Kamilah and Indah Dwi Pratiwi

Departement of Nursing, Faculty of Health Sciences, University of Muhammadiyah Malang,

alan Bendungan Sutami 188A

Malang, Indonesia 65145

Keywords: Self-Efficacy, Avoidance Behavior, Cigarette Smoke Exposure, Mother, Toddler.

Abstract: A mother play important role to protect her children from any dangerous substances. This includes protecting

her child from cigarette smoke exposure that contribute to the series of health problem. Self-efficacy of a

mother allows her to take a particular action needed in the difficult situation, one of which is avoidance

behavior of cigarette smoke exposure around her and her children. The aim of this study was to explore the

relationship between self-efficacy with avoidance behavior of cigarette smoke exposure among mothers with

toddlers. This was a cross sectional study of 73 mothers with toddlers who live in a house together with active

smoker, it selected using purposive sampling. Spearman rank analysis were perform to explore the

relationship between variables. Results off the 73 mothers, 90.4% had a high self-efficacy and 82.2% had

high levels of avoidance behavior. Spearman rank test showed sig. (2-tailed) value of 0.005. Correlation

Coefficient obtained was 0.324, it means that there were a positive relationship between self-efficacy and

avoidance behavior, with the strength of the relationship is in the moderate level. The more higher the level

of self-efficacy is accordance with the level of avoidance behavior of cigarette smoke exposure.

1 INTRODUCTION

Exposure to the environmental tobacco smoke (ETS)

in a household causes many health problems for the

member of family as the second hand smoker (SHS)

(Gavarkovs et al., 2018). As a source of pollution in

the indoor home environment, it contributes to the

several health problems, such as respiratory

infections, ischemic heart disease, lung cancer, and

asthma. It is predicted that more than 600,000 deaths

per year worldwide are caused by SHS which is more

than 1% of all deaths. Women and children are mostly

affected by exposure to SHS (WHO, 2014). The data

from United Nations Children's Fund (UNICEF) in

2015, showed that 5,9 millions children under 5 years

old has been die and 15% of it or around 920.000

children were died because of pneumonia, otherwise

stated that more than 2.500 of children under five

years old who die everyday because of pneumonia

that can be caused by environmental tobacco smoke

exposure (Karami and Kadarisman, 2017).

Environmental tobacco smoke (ETS) is a complex

and reactive blend between the main smoke exhaled

by smokers and the smoke emitted from the burning

tobacco and then this reacts with the surrounding air.

This blend contains over 4700 chemicals including

hazardous amines, carbonyls, hydrocarbons or metals

among others. SHS exposure can cause several

illnesses in nonsmokers including ischaemic heart

diseases in adults and lower respiratory infections and

asthma in adults and children, among other adverse

health effects (Torres et al., 2018).

A mother is both naturally and culturally plays

important role to take care the health of their children.

It includes protecting her self and children from any

hazardous exposure, such as cigarrete or tobacco

smoke exposure. A study showed that a mother who

did not take any action to avoid the cigarrete or

tobacco smoke exposure were significanly contribute

to the health problem of the children, for example like

bronchitis and asthma (Yilmazel, 2014). Therefore, it

is required self-efficacy especially for a mother in

facing every difficult situation, because the function

of self-efficacy is to ensure that she can solve every

problem and the more higher self efficacy, so the

more belief that she can be able to complete every

challenge (Hidayat, 2011). The research conducted

Masruroh, N., Al Kamilah, S. and Pratiwi, I.

Self-efﬁcacy and Avoidance Behavior from Cigarette Smoke Exposure: A Cross Sectional Study among Mothers of Under-ﬁve Year-old Children.

DOI: 10.5220/0009120800410047

In Proceedings of the 2nd Health Science International Conference (HSIC 2019), pages 41-47

ISBN: 978-989-758-462-6

by (Golestan and Abdullah, 2015) showed that self-

efficacy has a moderating effect on the relationship

between smoking behavior, pressure by peers and

also family members who smoke.

Parents have an obligation to keep family

members especially children, from the dangers of

exposure to cigarette smoke. Parents should provide

a smoke-free environment for themselves and family

members to avoid exposure to cigarette smoke.

Families who have family members who smoke are

considered difficult to avoid exposure to cigarette

smoke because of the interaction between each other

at all times (Perdana, Dhewangga Adi, Waspada,

2015). Behavior to avoid exposure of cigarette smoke

is very important to do in preventing the negative

effects of it. Families who do not take precautions to

avoid exposure to cigarette smoke are very vulnerable

to a series of health problems from cigarette smoke

exposure (Lin et al., 2010).

Avoidance behavior from exposure to cigarette

smoke in the family is considered to be still in a low

level, this is confirmed by research conducted by (Lin

et al., 2010) only found 6.2% which shows the

behavior of avoiding cigarette smoke exposure.

Avoidance behavior is a stimulus for avoidance that

is associated with unpleasant experiences to maintain

security (Pittig et al., 2014). Research conducted by

(Xu et al., 2017) explained that prevention measures

against cigarette smoke exposure by women vary

greatly. Some women more often to avoid and open

the window when the smoker is a friend or stranger,

and less often when the smoker is a mother or

husband. This study aims to determine the

relationship between self-efficacy and avoidance

behavior among mothers with toddlers to prevent the

effects of cigarette smoke exposure.

2 METHODS

This study used a correlative descriptive non-

experimental research design with a cross sectional

approach. The population used in this study was 218

mothers of under five years old children in

Sumbersari Village, Lowokwaru District, Malang

City. Purposive sampling technique was used in this

study with the sample criteria: Mothers who has

under five years old children and lived at home with

family members who are active smokers, and there

were 73 respondents who met the criteria. The self-

efficacy instrument was created by (Schwarzer and

Fuchs, 2016) which consisted of 10 questions on a

Likert scale. This model consists of positive

(favorable) and negative (unfavorable) statements.

Reliability on the General Self-Efficacy

questionnaire is between 0.76 and 0.90. The validity

of The General Self-Efficacy Scale correlates with

emotions, optimism, work, and satisfaction. Negative

coefficients were found for depression, stress, health

complaints, fatigue, and anxiety (Schwarzer and

Fuchs, 2016; Choudhury, Gopalan and Thukral,

2017). In this study researcher modified the general

self questionnaire -efficacy, so that it can be adjusted

to passive smokers.Validity test results obtained 7

statements declared valid.First-efficacy categorized

into the category of low = <17.5 and high category =

≥ 17.5.

Avoidance behavior scale from cigarette smoke

exposure used in this study was developed by

Martinelli in (Lin et al., 2010). This scale includes 19

items that assess respondents' efforts to prevent

exposure to cigarette smoke. The sub-scale is in the

form of a 4-point Likert scale (1 = always true; 2 =

usually true, 3 = usually incorrect; and 4 = almost

never true). Higher results will indicate avoidance

behavior from exposure to high cigarette smoke. The

Cronbach’s Alpha coefficient on this scale is 0.82.

This study uses a questionnaire that has been

translated and validated by (Gharaibeh et al., 2011),

but in this study the researcher modified the

questionnaire into 9 statements. The researcher used

a 3-point Likert subscale (1 = never, 2 = sometimes,

3 = always). Avoidance behavior is stated to be low

if the result is <18 and high if the result is ≥18. Both

of self-efficacy and also avoidance behavior from

cigarette smoke exposure instruments, have met the

standard of validity and reliability test.

Moreover, bivariate analysis in this study aims to

determine the relationship between self-efficacy and

avoidance behavior of cigarette smoke exposure in

mothers with children under five, using the Spearman

Rank (Rho) correlation test used to measure the level

or close relationship between the two variables with

an ordinal scale.

3 RESULTS AND DISCUSSION

The majority of 73 enrolled subjects were classified

into middle adulthood which number is 48

respondents or 65,8 %. Furthermore, the highest

percentage of subjects with an education level of

senior high school was 59%. Out of all 73 women in

this study, 57,29 % of their husbands smoked. The

characteristics of respondents were shown in table 1.

The result of univariate data analysis shown that

the majority of respondents who showed a high level

HSIC 2019 - The Health Science International Conference

of self-efficacy was 66 of 73 or 90,4%, as described

in the following table 2:

Next, for the more detail information about the

self-efficacy questionnaire, it can be looked through

the table 3. Majority of Respondents self-efficacy

revealed that mother has belief in the dimension of

generality, this is as stated in the first statement which

is: "If someone prevents me from avoiding exposure

to cigarette smoke, then I will try to find ways to get

rid of these obstacles" ( Table 3 ).

The results showed that the majority of

respondents had a high level of self-efficacy. The

majority of respondents used in this study are in the

middle adulthood age category and most of them have

senior high school education. Self-efficacy can be

influenced by several things, such as

sociodemographic (sex, age, location), life

experience and academic experience (de Fátima

Goulão, 2014; Alwisol, 2016; Ajayi and Olamijuwon,

2019). In addition, Badura's theory of self-efficacy

asserts that self-efficacy is developed through

personal experience, social learning and social

persuasion (Bandura et al., 1996; Schwarzer and

Fuchs, 2016). Thomas Armstrong, Ph.D., an award-

winning educator and expert on human development,

argued that the middle adulthood is the contemplation

phase, which someone in this period will take a break

from worldly responsibilities to reflect the deeper

meaning of their lives, the better to forge ahead with

new understanding, as a consequence she / he

becomes better and more mature in taking a stand.

Moreover, during this period individuals will evaluate

life experiences and redefine themselves in their roles

and values (Anas, 2013). In addition, a study

conducted by (de Fátima Goulão, 2014) using adult

respondents, showed the results that the average

respondent had high self-efficacy, as well as showing

a significant relationship between self-efficacy and

academic achievement.

Respondents with high self-efficacy will be sure

to be able to do something that has the potential to be

able to change events around their environment, and

will be more likely to take an action (Bandura et al.,

1996; Feist and Feist, 2010). Self-efficacy of mothers

with toddlers who live at home with active smokers

can influence the attitudes and behavior of mothers.

This is supported by (Bandura et al., 1996; Kurose,

2013) who explains that individuals with high self-

efficacy tend to set higher goals and achieve

challenging opportunities, while those who have low

levels of self-efficacy, seeing things become difficult

, and tend to do the opposite.

In addition to its role in goal setting and

opportunity selection, self-efficacy continues to

influence the behavior of individuals who are actively

pursuing their goals. Self-efficacy influences

behavior with resilience which leads to greater ability

and perseverance in facing challenges. Simply put,

self-efficacy is contained in a process that connects

human motivation, behavior, and performance

(Kurose, 2013).

Table 4 above describes the majority of

respondents had high level of avoidance behavior of

cigarette smoke exposure, it was 60 of 73 or 82,2%.

Furthermore, it can be seen in the table 5 that the

majority of mothers implement avoidance behavior

by making attempts to minimize exposure when they

are in a situation that is not possible to withdraw from

cigarette smoke exposure as stated in the statement 7,

that is : "if my husband or my family smokes around

me and my child then they don't want to stop smoking,

then I will turn on the fan or open the window so that

exposure to cigarette smoke can be reduced”.

The results of the study reports that the majority

of respondents have a high level of avoidance

behavior from exposure to cigarette smoke.

Respondents in this study are mothers who have

children under five years old. The majority of

respondents age in this study are middle adulthood

category. Another additional information from the

study is that all respondents live in the same house

with smoker, where the majority of smokers are

husbands.

A person's age can affect their behavior, in this

case it is related to avoidance behavior from exposure

to cigarette smoke. As explained above that the

mature age will strengthen one's behavior, especially

to maintain their health (Armstrong.T, 2019). The

status of family members as the highest active

smokers is a husband is a phenomenon that often

occurs in families, as research (Gharaibeh et al.,

2011), which stated that more than half of the

participants (55%) reported living with a husband

who smoked. More than one third (367%) of

respondents' husbands smoke in the house, and as

many as 24.9% of the study respondents report that

other family members also smoke at home. In total,

almost two-thirds (59.6%) of subjects reported that

their husband or other family members smoked in the

house. Traditionally, the husband is the head of the

family and holds the highest authority in the family,

so it is not easy for a wife to make strict rules about

prohibiting smoking at home. For this reason

avoidance behavior is one of the most frequent

attempts by women whose partners are smokers.

Private homes are the enclosed area where people

mostly spend the daily time, and only voluntary rules

are possible, have become a main source of exposure

Self-efﬁcacy and Avoidance Behavior from Cigarette Smoke Exposure: A Cross Sectional Study among Mothers of Under-ﬁve Year-old

Children

to SHS among children and nonsmoking adults

(Zheng et al., 2014), and will have a negative impact

on health if the mother does not do limiting or

practicing avoidance behavior (Lin et al., 2010).

Other results from this study found that the

majority of mothers implement efforts to minimize

exposure when unable to withdraw from exposure to

cigarette smoke. This result is supported by research

conducted by (Zheng et al., 2014) that the most

common step to reduce exposure to cigarette smoke

is to make a smoke-free policy in the house and take

actions such as opening a window so that cigarette

smoke can be reduced and not settled in the room.

Table 6 describes the results of crosstabulation

between self-efficacy and avoidance behavior from

exposure to cigarette smoke. From this table, it can be

seen that there are 66 respondents or 90.4% who have

high self-efficacy, from that number 54 (74%) of

respondents have high avoidance behavior from

cigarette smoke exposure and only 7 (9.6%)

respondents who have low self-efficacy, and there is

1 respondent (1.4%) who has low self efficacy as well

as avoidance behavior from cigarette smoke exposure

which is also low. In general, this shows that the

majority of respondents in this study had high levels

of self-efficacy and high avoidance behavior from

exposure to cigarette smoke.

Next, by using the Spearman Rank test, it

conducted an analysis of the relationship between

self-efficacy and avoidance behavior from cigarette

smoke exposure among mothers of under five years

old children in the Sumbersari village of Malang City,

the results are presented in table 7 below:

Based on table 7, it is known that Spearman's rho

correlation test results obtained p value = 0.005, this

is less than alpha (0.05), then H0 is rejected and H1 is

accepted, this means that there is a relationship

between self-efficacy and avoidance behavior of

cigarette smoke exposure among mothers. The

correlation coefficient (0.324) shows the level of

relationship between the variables of self-efficacy

and avoidance behavior from exposure to cigarette

smoke among mothers of under five years old

children is included in the category of sufficient

correlation. High self-efficacy will increase

avoidance behavior of cigarette smoke exposure. It

can be concluded that there is a significant

relationship between self-efficacy and avoidance

behavior of cigarette smoke exposure among mothers

of under five years old children.

The Spearman Rank test results obtained a P-

value of 0.005, then H1 is accepted and Ho is rejected.

The results of this study can be concluded that there

is a relationship between self-efficacy and avoidance

behavior to prevent cigarette smoke exposure among

mothers who have children under five years old and

the test results of correlation strength was 0.324, it

indicate that the strength of the relationship between

self-efficacy and avoidance behavior to prevent

cigarette smoke exposure is moderate.

Table 1: Characteristics of Respondents.

No Characteristics F (%)

1 Age (Years)

- 20–35 (Early

Adulthood)

- 36 - 65 (Middle

Adulthood)

- > 65

34,2 %

65,8 %

2 Level of Education

- Elementary School

- Junior High School

- Senior High School

- Diploma

- Bachelor Degree

1,4%

20,5%

59%

6,8%

12,3%

3 Total Number and The

Relationship the member

family who are smoker :

Son

Father

Father in law

Brother in law

Grand Father

Nephew

Brother

Husband

1,04%

16,7%

3,1%

9,4%

3,1%

1,04%

8,33%

57,29%

4 Duration ( year ) to be

smoker

No explanation/ forget

1-10

11-20

21-30

>30

28,1%

32,3%

29,2%

7,3%

3,1%

Table 2: Self-Efficacy of Mother who has under Five Years

old Children.

Self-Efficacy

Number of

Respondent

High Low

90,4% 9,6% 100%

66 7 73

Test results that have been done can be concluded that

the higher the self-efficacy, so the avoidance behavior of

cigarette smoke exposure will be higher. This result is

supported by (Friedman and Schustack, 2008), that self-

efficacy can determine whether someone will show a

certain behavior, how the strength of an individual to be

able to survive when facing difficulties or even failures, and

HSIC 2019 - The Health Science International Conference

how success or failure in a particular task or problem affects

individual behavior in the future.

Table 3: Frequency of Self-Efficacy Questionnaire.

No Questionnaire Statements Mean Rank

1 If someone prevents me from

avoiding cigarette smoke, then I

will try to find a way to get rid

of these obstacles

3.2603 1

2 I have no difficulty in carrying

out my goal to avoid exposure

to cigarette smoke

2.8493 7

3 I always know how to avoid

unexpected exposure to

cigarette smoke, such as by

asking smokers not to smoke or

by staying away from smokers

3.1233 3

4 I have a way to overcome the

incidence of cigarette smoke

exposure, such as refusing to

enter the environment where

there is cigarette smoke,

controlling and minimizing

cigarette smoke exposure

3.2192 2

5 I can avoid exposure to cigarette

smoke well because I always

rely on the ability that I have

3.0959 5

6 I can handle cigarette smoke

incidents such as by avoiding,

turning on fans, asking smokers

to stop smoking when facing

unexpected cigarette smoke

events that occur unexpectedly.

3.0274 6

7 I am ready to handle the

incident of cigarette smoke

exposure

3.1233 4

Table 4: Avoidance Behavior of Cigarette Smoke

Exposure.

Category

Avoidance

Behavior of

Cigarette Smoke

Exposure

(%) Total

High 60 82,2%

(100%)

Low 13 17,8%

High avoidance behavior will have a positive impact on

mothers and toddlers, because it can reduce the chance of

exposure to cigarette smoke which causes health problems

especially in vulnerable children. In practicing avoidance

behavior, a mother needs a strong belief that is self efficacy.

Mothers with toddlers who have high self-efficacy will take

the actions needed to maintain the health of themselves and

their children. This is in line with research which states that

the factors related to higher second-hand smoke avoidance

behavior were higher self-efficacy (Lee, Ahn and Lee,

2018).

Table 4: Frequency Avoidance Behavior of Cigarette

Smoke Exposure Questionnaire.

No Questionnaire Statements Mean Rank

1 When I see someone who is

smoking, I will keep my

distance to ensure that my child

and I are not exposed to

cigarette smoke

2.5890 3

2 If my child and I are gathering

with family members or other

people, then someone starts

smoking, then my child and I

will keep a distance or move

away from that place

2.6164 2

3 When my child and I are in

public places like restaurants,

offices, or clinics, I will leave if

I don't get a seat in the non-

smoking section

2.4110 4

4 I do not allow family members /

other people to smoke when

they are carrying my child

2.2192 7

5 When I travel together with my

child using public

transportation, then I will ask

the driver not to smoke for a

while

1.9041 9

6 I do not allow my husband or

other people to smoke while

riding a motorcycle or other

means of transportation when

there is my child in the vehicle

2.3973 6

7 If my husband or other family

members are smoking around

me and my child, then they don't

want to stop smoking, then I

will turn on the fan or open the

window so that exposure to

cigarette smoke can be reduced

2.6986 1

8 When I and other family

members are exposed to

cigarette smoke, then I will

wash the clothes that me and my

family member wear to

eliminate the smell of cigarette

smoke even though the clothes

are clean

1.9452 8

9 When my child and I travel by

motorcycle or public

transportation, I will use a nose

covering or ask for a seat that is

free of cigarette smoke and open

the window if someone starts

smoking

2.4110 5

Self-efﬁcacy and Avoidance Behavior from Cigarette Smoke Exposure: A Cross Sectional Study among Mothers of Under-ﬁve Year-old

Children

Table 5: Crosstabulation Self-Efficacy and Avoidance

Behavior of Cigarette Smoke Exposure.

Avoidance Behavior of

Cigarette Smoke

Exposure

Total

Low High

Self-

Effi

cacy

Low 1 (1,4%) 6 (8,2%)

(9,6%)

High 12 (16,4%) 54 (74%)

(90,4%)

Total 13 (17,8%)

(82,2%)

(100%)

Table 6: Correlation between Self-Efficacy and Avoidance

Behavior of Cigarette Smoke Exposure Among Mothers of

Under Five Years Old Children.

Correlation

Self-

Effica

Avoida

nce

Behavi

Spearm

an’s rho

Self-

Efficacy

Correlat

ion

Coeffici

ent

Sig. (2-

tailed)

1.000

.324

.005

Avoidan

Behavio

r from

Cigarett

Smoke

Exposur

Correlat

ion

Coeffici

ent

Sig. (2-

tailed)

.324

.005

1.000

Correlation is significant at the 0.01 level (2-tailed)

4 CONCLUSIONS

The majority respondents have a high level of self-

efficacy and also high avoidance behavior from

cigarette smoke exposure. There is a significant

relationship between self-efficacy and avoidance

behavior from cigarette smoke exposure. The higher

self-efficacy among mothers who have under-five-

years-old children, the higher the behavior to avoid

exposure to cigarette smoke.

ACKNOWLEDGEMENTS

My greatest gratitude for Allah S.W.T, the God who

blesses me great life. My thankfull also for my family,

the Dean of Health Science Faculty and all of the

University Leaders of University of Muhammadiyah

Malang for the great supports

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Self-efﬁcacy and Avoidance Behavior from Cigarette Smoke Exposure: A Cross Sectional Study among Mothers of Under-ﬁve Year-old

Children