Phase 1 - Interviews exploring barriers and facilitators of SFH .
Smoking behaviours
There was typically one smoker in each participant’s home, often the interview participants themselves. The number of times they smoked in the home ranged from one to eight times a day, usually in the morning and at night, during the day the men were out at work. Some said that they try to smoke on the balcony or in an empty room, which was difficult for the three families who live together in one room. Only one smoker claimed to never smoke in the home.
“I felt that the smoke will be harmful for my family members and I stopped smoking inside home.” (P01: Male, 35 years, Smoker, highly educated)
Barriers and drivers to achieving an SFH
Whilst all interview participants knew of the risks of smoking to the smoker, knowledge of the dangers of SHS varied and was better amongst the more educated, although they still underestimated the extent of potential harm.
"I know that it harms equally others who are around someone who is smoking. That is why I have quit smoking at home totally now.”
(P01: Male, 35 years, Smoker, highly educated)
The consensus was there were no disadvantages of having an SFH. Participants identified multiple benefits, mentioning particularly the positive impact on the health of family members, especially children. Indeed, this was seen to be the key motivator. Other benefits were seen to be eliminating the smell and improving air quality in the home, reducing the risk of an accidental fire and sons not copying their father’s smoking behaviour.
"Everyone loves their children. People would be ready to do anything for the betterment of their children. If they stop smoking at home then the air of that house would not be polluted. Wives and children of smokers will be able to inhale clean air and they will remain healthy. There would not be any bad smell of cigarette smoke in clothing. The overall environment of home will remain very good."
(P07: Male, 36 years, Smoker, moderately educated)
The key challenge to achieving an SFH was smokers ignoring requests to smoke outside the home. Several men acknowledged this, whilst one woman spoke of how it would be difficult for women to ask men to smoke outside, suggesting they may not listen or worse, react angrily. She hoped the men would be motivated themselves.
“She tells me not to smoke inside home, she has told me. Then, sometimes, I stop smoking inside home, then maybe after a few days, I start smoking in the home again, you know.”
(P07: Male, 38 years, Smoker, not educated)
"Motivating and convincing the smokers would be a challenge, I think. As in our society men are often dominating, it is not likely that all of them will listen, some of them may get angry hearing such things. In some families there might be conflict. If the smokers are motivated enough by themselves, it would be better.”
(P08: Female, 45 years, Non-smoker, highly educated)
Acceptability and feasibility of a mosque-based SHS intervention
All the interview participants thought it was a good idea to educate people about SHS through mosques; because of the credibility and influence of the Imam as a religious leader, and the mix of people who would hear the messages. Most had not heard health messages in the mosque before.
“Those who have faith in religion go to the mosque, that's why normally they should abide by the rules and regulations of the religion. As the Imam is a religious leader, people listen to him and discuss problems with him, if he talks about smoking, some people will definitely listen to those messages.”
(P01: Male, 35 years, Smoker, highly educated)
"People who go to the mosque regularly and on time are mostly guardians from families, the young generation like us are less in number. So, by them (these guardians) these kinds of messages can spread to others. Another thing would be best if we can make women in our homes more aware and they will definitely be able to make sure that nobody smokes at home."
(P06: Male, 34 years, Smoker, moderately educated)
The consensus was that the content of the messages would need to be tailored to the audience. Women and children would need knowledge about SHS to persuade family members not to smoke inside, and to protect themselves from smoke. Whereas the men would benefit from learning about SHS in the context of Islamic scripture.
“Women also need awareness. They will then tell the smoker family members not to smoke inside home. If children get to know the harms of SHS they would then try to protect themselves from second-hand smoking."
(P07: Male, 38 years, Smoker, not educated)
"The messages should vary. In the mosque the Imam can tell people about these (messages) with hadiths and Quran teachings. But for women there can be other things. For children the message should be in such form that they can communicate with their parents."
(P02: Male, 40 years, Smoker, limited ability to read)
In terms of feasibility, the time before Arabic Khutbah (when the largest proportion of a mosque's congregation attends) was seen as the sensible time to deliver the messages as most men attend then, thus maximising the size of the audience.
“We, poor people, rich people, everybody goes to Jum’ah prayer. It's like the Eid day. Old people, younger people, small children gather together. So, it would be good delivering these messages during Jum’ah prayer. Everybody will listen and give importance."
(P05: Female, 42 years, Smoker, not educated)
Other ideas for message delivery were Quran classes (for children), Madrasa classes and other congregations like Milad mahfil (a custom practised by many Muslims as an expression of reverence for Prophet Muhammad (PBUH)) and Waz mahfil (Islamic sermon in the communities) although these were acknowledged to reach fewer people and occur less frequently.
Phase 2 - Identification of programme theory and content
Based on the evidence of the previous utility of the model for understanding and intervening on smoking behaviour [42, 43] we selected the Theory of Planned Behaviour, extended with action planning and coping planning as the starting basis for the programme theory to guide the development of the intervention content (see Figure 1) targeting SHS. Using the interview findings and the selected programme theory, a Muslim colleague with knowledge of social cognitive constructs and the BCT taxonomy [39] supplied a list of ayahs that could support messages to promote change in potentially modifiable constructs that were identified as being present within the interview. We mapped the programme theory constructs findings were then mapped to BCTs [39] that seemed likely to result in changes in those constructs based on study team expertise.
The list of ayahs, the constructs targeted, the health messages, and the BCTs the health messages were mapped to is contained in Table 4.
(insert) Table 4: Initial ayahs, constructs, messages and coded BCTs
Phase 3 - User testing of candidate intervention content Results
All participants understood the general meaning of the ayahs and the health messages as well as the links between the two. Small edits to the precise wording of some of the public health messages were made, to improve comprehension; for example, for the message linked to Ayah Sura At-Takaathur (see Table 4, ayah 4) the concept of “worldly pleasure” was unclear to some leading to a suggestion to reword this. No major changes were deemed necessary at this stage.
Phase 4 - Iterative intervention development workshops with Imams and khatibs Imams’ experience and views of delivering health promotion messages
There was a view amongst the Imams that they talk about health-related issues in the mosques only when directly relevant to religion, for example, addiction to smoking or alcohol or eating good foods; or when prompted by a current public health issue such as an outbreak of disease where they may advise on disease prevention strategies.
“Addiction and smoking are sometimes discussed in mosques because it is destroying our children and adults, taking them away from Allah. There are young people who are always behaving badly to their parents. They are acting unaware of the consequences both in this world and the hereafter.”
(B07: Imam, khatib and Principal)
"Allah has even told us to eat pleasant foods... Drugs, smoking, these are already Haram by Allah's law and moreover there are unpalatable, stinky food, which is why these are harmful for health."
(A06: Imam)
"A few days ago, city corporation people came to us and told us to talk on Chikungunya in Jumu’ah prayers. So, we did this."
(B03: Imam and khatib)
The exception was during Ramadan when there is more emphasis on changing people’s “bad” behaviours and helping them to focus more on praying to Allah.
They were generally motivated to deliver health messages in mosques and familiar with including messages during Khutbah in Jumu’ah prayer about behaviours that harm people both physically and spiritually. Educating men about the risks of smoking and SHS was seen as a good idea, particularly as people rarely learn about SHS, so the intervention was considered to represent an opportunity, with the input of international researchers seen as an asset. Additionally, this perceived scientific foundation of the intervention was seen as important as Imams did not consider themselves experts on public health, rather their expertise was in spiritual matters.
"Actually, you have to pray to Allah from Dunya (this world). After death, there is no chance for earning good deeds. So, for earning good deeds, the first condition is Haya (life). Abstaining from addiction what Allah prohibited and what the prophet (PBUH) did and encouraged us to do, if we follow those, the Hayat will increase."
(A01: Imam)
“If we can tell them about some medical facts on smoking along with religious messages on it, they will be more aware of it.”
(B04: Imam)
“We have both indirect and direct smoking here which is very bad. People do not hear much about second-hand smoking from anyone I guess.”
(B02: Iman and Teacher)
"So, if we get a booklet or guideline including information on medical science, and if the messages are included by studying Quran and Hadith, then these will be more acceptable. People will understand that not only Imams know about Quran and Hadiths but also are knowledgeable of other fields."
(A02: Iman and khatib)
They were also happy to deliver messages about planning, attempting and failing to change behaviours, observing that people are used to this, and Islam teaches them how to face such situations, with Imams seen as a trusted source of support.
“I think this is a great opportunity for Imams and common people because thousands of people can be reached with these messages and thus, Imams can make more people aware.” (A05: Imam and khatib)
Jumu’ah prayers on Fridays was seen as the most appropriate time to deliver the messages, as this is when there are large numbers of people in the mosque, and they have time to elaborate on the meaning. There was a view amongst some that it would be important to deliver a message one week, discuss it the next week and then return to it several weeks later as a reminder.
Feedback on ayahs and health messages
Imams were keen to undertake a careful check of the selected ayahs and proposed links with health messages. Some wanted more time outside of the workshop to do this work; whilst others advised that alims (Islamic scholars) should review the final list of ayahs and associated health messages.
There was agreement that the same ayahs and linked public health messages were appropriate for all mosques. The Imams’ suggestions for the 12 ayahs (listed in Table 4) are summarised below. The consensus across both workshops was that ayahs 3, 5, 7, 9, 12 were appropriate; and that ayah 4 was not suitably linked to the public message, although no one had an idea for a replacement. For the others, suggestions for alternatives were offered. These were usually to avoid misinterpretation or strengthen the take-home message. For two ayahs, changes were proposed to correct the meaning in the context of Islamic scripture.
Ayahs 1 and 10 were considered by some Imams to be open to misinterpretation. For Ayah 1, there was some concern that people might think that smoking is beneficial. Ayah 10 was seen as confusing about the type of knowledge being referred to; it should be understood to be knowledge of religion not knowledge of the harms of SFH. For ayahs 6 and 12, some Imams wanted to strengthen the message about the forgiveness of Allah. Alternatives for ayah 8 were offered to further encourage people to change their smoking and second-hand smoke behaviours by emphasising the importance of following the life and guidance of the prophet.
The two ayahs that were questioned in terms of religious accuracy were 2 and 11. For ayah 2 precision was needed that it is the Imam (not the scientist) who has authority to advise on what harms and heals to be consistent with the laws of Sariah. For ayah 11, the selected ayah was referring to divorce hence inappropriate.
As a result of the workshops, half the Ayahs were replaced with different Ayahs that better conveyed the messages or were more closely related to the public health messages targeted to be delivered. Ayah 1, 6, 8, 10, 11 and 12 were changed. Ayah 1, 8, 10, 11 and 12 were replaced with Ayahs suggested by the scholars of the Islamic Foundation, Bangladesh and Ayah 6 was replaced with another Ayah chosen by ARK researchers (see Table 5).
(insert)Table 5: Post-feedback ayahs, with linked constructs, health messages and coded BCTs
Format of the intervention content
The final version of the intervention was formatted as a booklet for Imams that contained the Arabic ayah, a translation into Bangla, and the related health message (see figure 2 for examples translated into English).
The intervention booklet finally contained 12 ayah and related health messages in total (see table 5). Training on delivery of the Intervention was provided over a half-day and was supported by a training manual. Training materials are available at [https://www.york.ac.uk/healthsciences/research/public-health/projects/mclass11/#tab-3]. Imams or khatibs in the mosques that were randomised to deliver the SFH intervention received copies of the intervention booklet to distribute to their congregation members after Friday Jumu'ah prayers or in study circles. Intervention delivery started immediately after training and continued for 12 weeks. Full details of the trial procedures have been previously published [9].