Your privacy, your choice

We use essential cookies to make sure the site can function. We also use optional cookies for advertising, personalisation of content, usage analysis, and social media.

By accepting optional cookies, you consent to the processing of your personal data - including transfers to third parties. Some third parties are outside of the European Economic Area, with varying standards of data protection.

See our privacy policy for more information on the use of your personal data.

for further information and to change your choices.
Skip to main content
Download PDF

Effectiveness of a Health Belief Model-based integrated health education and mobile phone short message service intervention on health knowledge, perception, and self-efficacy toward smoking: a quasi-experimental study among industrial workers in Myanmar

BMC Public Health volume 25, Article number: 1562 (2025) Cite this article

Abstract

Background

Comprehensive interventions are needed for smoking concerns among industrial workers. This study aimed to evaluate the effectiveness of a Health Belief Model-based integrated health education and mobile phone short message service intervention on improving health knowledge, perception, and self-efficacy toward smoking among industrial workers in Myanmar. This study uniquely integrates Health Belief Model-based health education sessions with short message service over three months, addressing the specific needs of this demographic.

Methods

A quasi-experimental study involved 146 workers per group in Mandalay Industrial Zone, Myanmar. A Health Belief Model-based intervention included six health education sessions and daily short message service with weekly repeated content for the intervention group. The outcomes were health knowledge, perception (susceptibility, severity, barriers, and benefits), and self-efficacy, assessed at baseline, immediately after the 3-month training, and 3 months post-training completion in both groups. Homogeneity between groups at baseline was assessed using the chi-square test and the independent t-test. Between-group differences were compared using the independent t-test, and within-group changes were evaluated using repeated measures ANOVA. Generalized Estimating Equations was applied to adjust for baseline differences between groups, accounting for variables such as age, marital status, education status, income, age at first cigarette smoked, and years of smoking cigarettes. Significance level was set at p < 0.05.

Results

Health knowledge in the intervention group significantly increased at immediately after the 3-month training but slightly declined at 3 months post-training completion (p < 0.001). Compared to the control group, perceived susceptibility, severity, barriers, and benefits, as well as self-efficacy, improved significantly immediately after the 3-month training (p < 0.001). Generalized Estimating Equations analysis revealed significant Group × Time interaction effects, showing positive effects on health knowledge (B = 0.991, p < 0.001), and notable improvements in perceived susceptibility (B = 5.091, p < 0.001), severity (B = 3.973, p < 0.001), barriers (B = 3.823, p < 0.001), benefits (B = 1.797, p < 0.001), and self-efficacy (B = 1.742, p < 0.001).

Conclusions

This study’s intervention significantly improved the health knowledge, perception, and self-efficacy toward smoking among industrial workers in Myanmar, highlighting the importance of targeted workplace interventions.

Peer Review reports

Introduction

Smoking contributes to preventable disease and death, which is a global public health concern [1]. Over eight million people die from tobacco-related causes annually; this number includes both smokers who are currently in active use and an estimated 1.3 million people who are not smokers but who die from secondhand smoke exposure [2]. There has been a rise in the burden of disease associated with current smoking behavior, which is particularly evident in countries with low to middle incomes [3]. Tobacco use continues to be a major public health concern in Myanmar, a lower-middle-income country (LMIC), with an adult smoking prevalence of 19.6% in 2022 (36.5% among men, 3.1% among women), causing 56,841 deaths annually and accounting for 11.2% of all deaths in 2021 [4]. Despite tobacco control efforts in Myanmar, policies lack robustness and effective implementation, necessitating more effective intervention strategies. Several diseases, such as cancer, lung diseases, stroke, heart disease, chronic obstructive pulmonary disease (COPD) and diabetes, have been related to cigarette smoking [5]. In Myanmar, the latest available data from 2016 shows the highest tobacco-related deaths from COPD (14,401), followed by other diseases (11,190), lung cancer (10,417), hemorrhagic stroke (7,538), ischemic heart disease (7,280), ischemic stroke (3,642), lower respiratory infections (3,334), asthma (2,376), tuberculosis (1,951), and diabetes (1,904) [6].

Despite the negative effects and the desire to stop using tobacco, the addictive substance nicotine, which is present in tobacco products, keeps people using it [7]. In order to reduce the global burden of chronic conditions particularly those linked to tobacco use and smoking, and to promote health and prevent disease, health education (HE) is essential [8, 9]. Nowadays, mobile phone-based HE interventions are becoming more and more common because of advances in technology around the world. Numerous benefits of mobile health (mHealth) interventions in terms of health outcomes have been found [10]. The World Bank [11] reported that since 2015, mobile phone ownership in Myanmar has increased dramatically; however, disparities persist, particularly in rural areas, with notable gender differences in mobile and internet usage. These disparities may hinder the effectiveness of mHealth interventions, as differing levels of access can restrict engagement with and utilization of health programs among underrepresented demographics, including industrial workers.

Smoking can have a negative impact on employees’ health, increasing the risk of chronic illnesses, mortality, decreased productivity, and even unemployment. Myanmar faces unique challenges in tobacco control, including high smoking prevalence, cultural norms, and gaps in public health resources. While many countries deal with active and secondhand smoke, weak enforcement of tobacco policies and limited access to cessation programs exacerbate the crisis. The possible relationships between workplace exposures and their effects on health outcomes have been the focus of many studies in the field of occupational health [12]. However, there is limited literature specifically addressing smoking-related health knowledge, perception, and self-efficacy among industrial workers in Myanmar. Furthermore, the research culture in Myanmar is still developing, resulting in limited available data and studies in this area. It is imperative for health of the industrial workers to identify smoking cessation methods that are successful.

The Health Belief Model (HBM), developed in the 1950s, is a key framework for understanding health behavior, using concepts like perceived risks, benefits, barriers, and self-efficacy, and is widely applied in health education interventions, where it has proven effective [13, 14]. Our study utilized the HBM both as a foundation for designing the intervention and as a framework for measurement, ensuring a comprehensive application of its concepts.

Studies on effective interventions have mainly focused on either HE programs, such as web-based [15] and audiovisual [16] approaches, or mobile phone short message service (SMS) initiatives [17,18,19]. While some interventions incorporate HE messages within SMS, our study uniquely implements separate HE sessions alongside tailored SMS messages, specifically targeting smoking cessation among industrial workers, representing the first of its kind in the context of Myanmar. Moreover, this integrated approach will address a notable gap in research, particularly in LMICs, where effective intervention strategies are critical in combating public issues like tobacco use. There are significant gaps in information, research, and intervention efforts within Myanmar aimed at promoting healthy behaviors and enhancing healthcare services. Therefore, this study aimed to evaluate the effectiveness of a Health Belief Model-based integrated health education and mobile phone short message service intervention on improving health knowledge, perception, and self-efficacy toward smoking among industrial workers in Myanmar.

Methods

Study design, study setting, study population, and study period

This study is part of a smoking cessation intervention research project and utilized a quasi-experimental design with a purposeful selection of Mandalay city. Mandalay, as the second-largest city and economic hub in upper Myanmar, is home to the second-largest industrial zone, housing a total of 794 industries in 2018 [20]. Moreover, the available data shows the prevalence of smoking in Mandalay was 84.9% in 2005 [21]. The target population of this study was industrial workers from Mandalay industrial zone. This study was conducted from 2018 to 2019.

Inclusion and exclusion criteria

This study included industrial workers aged 18 years and above, specifically targeting on those who smoke. Additionally, participants needed to possess daily access to a mobile phone and be proficient in reading SMS in Burmese alphabets. To ensure eligibility, participants were screened through a questionnaire assessing their previous or current involvement in smoking cessation programs, including questions about the type of program (behavioral therapy, pharmacotherapy, and counseling) they participated in, the duration of involvement, and any cessation methods used. Although individuals currently participating in cessation programs at the time of the study were to be excluded, none of the participants in our study were currently participating in other cessation programs or had participated previously. This information was corroborated through follow-up interviews to verify the accuracy of their responses. Additionally, pregnant female industrial workers and eligible individuals who declined to participate were excluded from the study.

Sample size and sampling technique

The sample size was determined using the formula for testing the difference in two independent proportions: n per group = 2 (Zα/2+Zβ)2 × p (1-p)/Δ2, where Zα/2=1.96 (two-sided significance level of 0.05), Zβ=0.84 (power of 80%), p is the average of the two proportions being compared, and Δ = minimum detectable difference between the two proportions (p1-p2) based on the proportions of self-reported 7-day smoking abstinence (p1 = 0.32 and p2 = 0.16) observed in a previous study [22]. The calculated sample size was n = 2 (1.96 + 0.84)2 × 0.24 (1-0.24)/(0.16)2 = 112 in each arm. Considering a 30% expected decline in participation and dropout rate, the adjusted sample size was set at 146 industrial workers per group, totaling 292 participants.

The Mandalay Industrial Zone committee was then contacted after Mandalay City and the Industrial Zone were purposefully chosen for this study. Initially, 794 industries were purposively matched based on the following criteria: (1) industry size (at least 300 to 350 workers), (2) type of industry (machinery production), (3) salary (100,000 to 300,000 MMK per month), (4) balanced gender distribution, (5) working hours (8 h a day with one day off), and (6) different blocks to minimize contamination risk. Seventeen industries met these criteria. From these, two industries were randomly selected using a computer-generated sampling method (https://www.randomizer.org/) and assigned to either the intervention or control group.

A systematic random sampling method was used to select participants for each group, inviting and getting informed consent from each industrial worker before assigning them a unique identifying number. This study was not blinded, as participants and researchers are aware of group assignments: the intervention group received HE sessions and SMS, while the control group receive non. Contamination was minimized since participants do not interact and industries were geographically distinct. After allowing for rejections and exclusion criteria, this sampling process was repeated until 146 participants in the intervention and control groups were reached. Figure 1 depicts the study flow chart.

Fig. 1
figure 1

The study flowchart

Full size image

Description of activities

Intervention group

An HBM-based integrated HE session and SMS messages were conducted in the intervention group.

Health education session

The content of the HE sessions were developed by a multidisciplinary team comprising the researcher, a general practitioner, and specialists in smoking studies, ensuring cultural relevance by integrating local norms and practices. Based on the “HBM”, these sessions incorporated constructs such as perceived susceptibility, severity, barriers, benefits, and self-efficacy to tailor the intervention to the cultural context of Myanmar [23, 24]. These sessions and information were developed and conducted between 2018 and 2019, and the information used remains consistent with the current updated literature [25]. The program, which lasted three months and included six sessions of 90 min each, addressed topics such as “the prevalence of smoking globally”, “the susceptibility of health problems associated with it”, “the severity of smoking”, “the barriers to quitting”, “the benefits of cessation”, and “the self-efficacy of smoking”. Six groups, each consisting of twenty to twenty-five participants, were set up. Detailed descriptions of HE sessions are provided in the Supplemental Material 1.

Session adherence was monitored through systematic attendance tracking, documenting participant presence for each session. Engagement was enhanced through strategies such as organizing sessions on paid working days and using the office venue at the industry, both as permitted by industry management, along with active learning approaches, including well-designed PowerPoint presentations and interactive discussions that encouraged participant interaction and dialogue. These mechanisms ensured consistent participation and reinforced intervention reliability with clear adherence and engagement metrics.

The researcher conducted HE sessions with three volunteers from non-government organizations (NGO) serving as co-facilitators. Before the sessions, co-facilitators underwent assessments and training, and preparation discussions were conducted the day before each session.

Mobile phone based short message service

The team responsible for developing the HE sessions also designed the mobile phone SMS messages, incorporating content from both the HE sessions and the volunteer handbook of the Tobacco-free region. This handbook, published in 2016 by Southeast Asia Tobacco Control Alliance (SEATCA) and People Health Foundation (PHF) Myanmar, is available exclusively in printed form and is written in the Myanmar language; this book is not available online.

SMS messages were delivered to industrial workers at 18:00 P.M. in the evening to ensure they were read, considering potential mobile phone inaccessibility during working hours. Following the recommendations of the World Health Organization [24], these messages addressed a range of subjects over the course of seven days:

  • Day 1: Global prevalence of smoking.

  • Day 2: Susceptibility and Severity of smoking.

  • Day 3: Composition of cigarettes.

  • Day 4: Barriers to not smoking.

  • Day 5: Benefits of not smoking cigarettes (Part A).

  • Day 6: Benefits of not smoking cigarettes (Part B).

  • Day 7: Self-efficacy (coping skills and healthy behaviors).

Following the completion of day 7, the message from day 1 was reintroduced on the subsequent day, and this cycle continued to repeat until another day 7. This process continued throughout the entire 3-month period. Detailed descriptions of SMS messages are provided in the Supplemental Material.

To ensure the readability and comprehension of the SMS messages, a pre-testing phase was conducted with a focus group of participants who shared similar demographic characteristics. Participants provided feedback on clarity, understanding, and relevance of the message content, and adjustments were made based on this feedback to enhance message effectiveness. To assess engagement, participants were asked in person at the industry every 7 days regarding their message check frequency and helpfulness; they were encouraged to note key messages received each week for discussion, while the research team maintained a log of all message sent. Through prior assessments and a review session with the investigator, three trained NGO volunteers ensured that the intervention group received SMS reminders that were accurate in content and clear in presentation.

The three-month duration of our intervention is supported by evidence from smoking cessation studies [17, 18, 22, 26], which emphasize the importance of sustained engagement for effective behavior change and provide participants with sufficient time to absorb the delivered information.

Control group

Participants in the control group were thoroughly informed about the study and their assignment. They did not receive any HE sessions or SMS messages during the intervention period. To uphold ethical standards, the control group was provided with the same HE content that was delivered to the intervention group during the study after its completion. This content was conducted at the industry office on employer-paid working days, but the participation did not extend over the full three-month program.

Recruitment period

The recruitment period started on May 7, 2018, and by May 28, 2018, each group had attained the required sample size. Baseline data collection commenced on June 1, 2018, followed by the implementation of the stipulated number of HE sessions and SMS messages sent to mobile phones, as well as timely outcome measurements as specified.

Data collection tools and process

A structured, interviewer administered questionnaire was used to conduct the face to face interview. This study adopted the widely recognized HBM and reviewed prior research to establish construct validity. This study utilized four parts of the questionnaire from a smoking cessation intervention research program among industrial workers in Myanmar. The questionnaire was developed based on existing literature, ensuring validation and acceptable reliability. Three experts in the field of smoking study confirmed the content validity. To ensure linguistic accuracy, the questionnaire was translated from English to Myanmar and then back again. Four parts of the questionnaire were used as follows;

  1. (i)

    Socio-demographic characteristics and smoking history: This part included age, sex, marital status, education status, monthly income, age at first cigarette smoked, and years of smoking cigarettes. These details were not reassessed immediately after the 3-month training or 3 months post-training completion.

  2. (ii)

    Health knowledge: This section comprised 10 questions adopted from a previous study [27] to assess the health knowledge of the participants regarding smoking-related diseases, and remains consistent with the current updated studies [5, 28]. The answers were categorized as “Correct,” “Incorrect,” “Not Sure,” and “Unknown”. Each correct answer scored 1 point, while incorrect, unsure, and unknown responses received a score of 0. The total score ranged from 0 to 10 points, with a higher mean score indicating greater health knowledge.

  3. (iii)

    Perception toward smoking: This part measured four perceptions using a 5-point Likert scale adopted from previous studies [23, 29]: susceptibility (11 positive statements), severity (10 positive statements), barriers (7 negative statements), and benefits (5 positive statements), and is aligned with the recent study [25]. Responses ranged from “Strongly Disagree” to “Strongly Agree”. After calculating the total scores, the mean score was determined; a higher mean represented a higher perception.

  4. (iv)

    Self-efficacy: This part adopted and employed the six-item “Smoking Abstinence Self-Efficacy Questionnaire” (SASEQ) developed by Spek et al. [30] to assess participants confidence in abstaining from smoking across various settings, and it is also congruent with the updated study [31]. The options on the rating scale were “Certainly Not (0)” to “Certainly (4)”. The scores were in the range of 0 to 24, where a greater mean indicated higher levels of self-efficacy.

The interview was conducted by three experienced volunteers proficient in health survey administration. They received training in trust-building, interview techniques, and unbiased administration before conducting the interview. The respective industry served as the venue for the interviews.

Outcomes measurement

This study evaluated the effect of an HBM integrated HE and SMS intervention, on health knowledge, perception, and self efficacy. The outcomes were assessed at baseline, immediately after the 3-month training, and 3 months post-training completion for both the intervention and control groups, using the same data collection tool.

Data analysis

The SPSS program (Version 22) was used to analyze the data. Categorical variables were presented with frequency and percentage, while mean and standard deviation (SD) described continuous data. To evaluate homogeneity between the intervention and control groups at baseline for inferential statistics, the chi-squared test was employed for categorical data and the independent t-test for continuous data. To compare the mean changes in health knowledge, perception, and self-efficacy between groups, the independent t-test was employed, and repeated measures ANOVA assessed changes within each group across the three time points. Generalized estimating equations (GEE) was applied to control for statistically significant differences between groups at baseline, adjusting for variables such as age, marital status, education status, income, age at first cigarette smoked, and years of smoking cigarettes. Moreover, the purpose of using GEE analysis was to examine the effect of the intervention on health knowledge, perception, and self-efficacy, while considering the effects of time, groups and interactions [32]. A statistically significant p-value was determined as less than 0.05.

Results

In this quasi-experimental study conducted in Mandalay, Myanmar, there were a total of 146 industrial workers included in both the intervention and control groups.

Table 1 displays socio-demographic characteristics and smoking history. The groups’ mean ages were 33.3 ± 10.9 in the intervention group and 28.2 ± 8.1 in the control group, respectively (p < 0.001). Compared to the control group (32.8%), the intervention group (45.9%) had university level education. The monthly income of intervention group was 190,342.5 ± 19,348.5 MMK (91 USD: 1 USD, valued on January 19, 2024, by the Central Bank of Myanmar [33], is equal to 2,100 MMK), whereas the control group was 171,164.4 ± 15,909.7 MMK (82 USD: 1 USD, valued on January 19, 2024, by the Central Bank of Myanmar [33], is equal to 2,100 MMK), indicating a significant difference (p < 0.001). Furthermore, the intervention group had greater age at initial cigarette smoking and years of smoking cigarettes (p < 0.001 and p = 0.004, respectively).

Table 1 Socio-demographic characteristics and smoking history
Full size table

Table 2 illustrates outcome changes over time in intervention and control groups. In the intervention group, knowledge significantly increased at immediately after the 3-month training but slightly decreased at 3 months post-training completion (p < 0.001). Perception scores in susceptibility, severity, barrier, and benefit significantly improved at immediately after the 3-month training (p < 0.001). The intervention group also maintained higher self-efficacy than the control group at immediately after the 3-month training (p < 0.001).

Table 2 Changes over time between and within intervention and control groups on health knowledge, perception and self-efficacy
Full size table

Changes over time (interaction between group and time) between and within the intervention and control groups are shown using GEE in Table 3. Adjusting for other variables, the knowledge scores in the intervention group were 1.156 times higher than the control group (p < 0.001), with 0.991 times change over time (p < 0.001). Perception (susceptibility, severity, barrier, benefit) showed significant changes (p < 0.001) between control and intervention groups over time (5.091, 3.973, 3.823, 1.797). Intervention participants had 1.971 times higher average self-efficacy scores than controls (p = 0.002), with changing self-efficacy scores (1.742) over time (p < 0.001).

Table 3 Changes over time between and within the intervention and control groups using GEE
Full size table

Discussion

The findings from this study highlight the effectiveness of combining HE sessions with mobile phone SMS reminder intervention in enhancing health knowledge, perception, and self-efficacy toward smoking among industrial workers in Myanmar.

All respondents in this study were male because female participants could not be identified. This finding aligns with previous research on cigarette, alcohol use, and physical activity among Myanmar youth workers in Thailand [34], which also reported no female participants. Similar trends were observed in studies examining the effectiveness of a site-based smoking cessation intervention among unionized building trade workers [35], and gender differences in smoking behavior among Thai university students [36], where very few females were included. The absence of female respondents in this study may be attributed to cultural norms in Myanmar, where smoking and alcohol consumption are often stigmatized among women, leading to reluctance in disclosing their smoking status [37].

The intervention group had a higher percentage of participants with advanced education than the control group, which may have contributed to the substantial difference in baseline health knowledge score between the two groups. This result is consistent with a study showing a correlation between health knowledge and educational attainment [38]. Health knowledge significantly improved in the intervention group immediately after the 3-month training and remained elevated at the 3-month post-training assessment compared to baseline. After adjustments, the intervention group had 1.15 higher average knowledge scores than the control group (p < 0.001), with a 0.99 change over time. This finding aligns with a study on smoking cessation among unionized building trade workers [35] and a randomized control trial on a tobacco de-addiction program for college degree students [39], where health knowledge significantly increased after intervention.

In order to treat tobacco-related diseases globally, health promotion is essential, with a focus on smoking cessation and prevention [16]. The HBM-based intervention enhances smokers’ health knowledge, addressing smoking concerns among Myanmar’s industrial workers. Adding community support, more cessation resources, mobile health tech, and smoke-free policies can further improve and sustain these efforts.

When compared to baseline, perception in the intervention group, such as susceptibility, severity, barriers, and benefits, increased significantly. Perceived susceptibility notably rose at both immediately after the 3-month training and 3 months post-training completion. This finding aligns with an Iranian study on smoking preventive behaviors [40], which highlighted that enhanced HE interventions can elevate perceived susceptibility. However, another Iranian study observed that middle school students experienced reduced perceived susceptibility following a preventive education intervention for cigarette smoking, suggesting that the effectiveness of such programs can vary by age and educational context [41]. Variations in perceptions may stem from differences in interventions design and delivery. For instance, older participants often showed greater acceptance and awareness of their susceptibility to smoking-related health issues, possibly due to intervention content and delivery methods tailored to their experiences. In contrast, younger participants may require strategies that address specific social influences and communication styles suited to their contexts.

Perceived severity, barriers, and benefits in the intervention group increased significantly at 3 months post-training completion, aligning with findings from an Arab nation study on smoking prevention measures that underscore the potency of HE grounded in the HBM [42]. Perceived susceptibility, severity, barrier, and benefit scores between the control and intervention groups significantly increased over time, as determined by GEE analysis in this study, showing similar consistent improvements in perception as seen in related studies using the HBM [43, 44]. Ongoing HE interventions based on the HBM can positively shifts perceptions, particularly when tailored to socio-demographic, socioeconomic, and cultural factors. Focusing on specific health hazards linked to smoking, rather than simply providing general knowledge, may more effectively influence perceptions and foster a sense of urgency among different demographic groups. Furthermore, intervention adjustments, such as relatable scenarios and peer-led discussions, can enhance participant engagement and susceptibility awareness, while culturally relevant HE shapes smoking risk perceptions.

The self-efficacy scores, initially comparable between intervention and control groups at baseline, showed significant increases in the intervention group immediately after the 3-month training and 3 months post-training completion. The intervention group demonstrated a substantial rise in average self-efficacy scores compared to the control group, supporting the study’s hypothesis. This aligns with findings from similar HE programs, indicating notable improvements in self-efficacy after HE intervention [45, 46]. The study’s health education sessions and SMS interventions likely enhanced participants’ self-efficacy by providing information, skills, and confidence needed to refrain from smoking in diverse settings. The structured approach and use of behavior theories like the HBM may have positively influenced participants’ beliefs about their ability to quit smoking.

Strengths of the study

In order to improve health knowledge, perception, and self-efficacy toward smoking, this study combines HE sessions with SMS based on the HBM. As the first study of its kind in Myanmar, it addresses a major literature gap and highlights the need for further scholarly discussion. This study contributes to the ongoing exploration of HE interventions for smoking cessation in Myanmar, suggesting avenues for future research to deepen understanding of its specific impacts and contextual relevance. This study is a pioneer in Myanmar, focusing on industrial workers and smokers through HE sessions and SMS. Setting a standard for future initiatives throughout the region, the innovative approach expands the scope of health intervention options and provides a distinct model applicable to a variety of health-related circumstances in Myanmar.

Limitations of the study

The lack of individual randomization in the quasi-experimental design may introduce selection bias, underscoring the need for future randomized controlled trials. Identifying only male smokers may limit conclusions about female smokers. Additionally, some outcomes exhibited large SD values, indicating substantial variance within the data, which may affect the generalizability of the results and should be interpreted with caution. While the intervention assessed self-efficacy, a key construct of the HBM, through scenarios related to managing temptations and social situations, the broader influences of peer support and peer pressure within each group were not specifically analyzed. Although efforts were made to minimize contamination between groups, these social dynamics may still affect outcomes. Future research should include an examination of the roles of peer support and peer pressure in shaping self-efficacy and enhancing the effectiveness of health interventions. The specific focus on industrial workers in Myanmar may further limit the applicability of the findings to other populations or settings. Despite baseline differences, typical in quasi-experimental studies [47], this study applied GEE analysis to control for time, group, and interaction effects, addressing implications for evaluating intervention effectiveness [24]. The 3 months post-intervention completion assessment may limit long-term impact evaluation; future research should extend the evaluation period to ensure sustainability.

Conclusions

This study, employing an integrated approach of HE sessions and mobile phone SMS reminder within the HBM framework, demonstrated significant positive impacts on health knowledge, perception (susceptibility, severity, barriers, and benefits), and self-efficacy toward smoking among industrial workers in Myanmar. Engaging a diverse group of stakeholders, including policy makers, healthcare professionals, community-based organizations, and non-governmental organizations, is crucial for effectively tackling the smoking epidemic and maximizing the effectiveness of these interventions. Although cultural relevance was considered in developing the materials, qualitative research and community engagement are recommended for better alignment and refinement. Further studies should explore the generalizability and sustainability of integrated HE sessions and SMS interventions, considering diverse populations and occupational sectors.

Data availability

The data of this study can be obtained from the corresponding author upon reasonable request and subsequent review by the author.

Abbreviations

HBM:

Health Belief Model

HE:

Health education

SMS:

Short message service

GEE:

Generalized Estimating Equations

References

  1. Centers for Disease Control and Prevention. Diseases and Death: Centers for Disease Control and Prevention; 2022 [cited 2023 25 December]. Available from: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/diseases-and-death.html

  2. World Health Organization. Tobacco: Key Facts: World Health Organization; 2023 [cited 2023 25 December]. Available from: https://www.who.int/news-room/fact-sheets/detail/tobacco

  3. Dai X, Gakidou E, Lopez AD. Evolution of the global smoking epidemic over the past half century: strengthening the evidence base for policy action. Tob Control. 2022a;31(2):129–37. https://doi.org/10.1136/tobaccocontrol-2021-056535.

    Article  PubMed  Google Scholar 

  4. The Tobacco Atlas. Country Factsheets: Myanmar: The Tobacco Atlas 2024 [cited 2025 15 March]. Available from: https://tobaccoatlas.org/factsheets/myanmar/

  5. Centers for Disease Control and Prevention. Smoking and Tobacco Use: About Health Effects of Cigarette Smoking: Centers for Disease Control and Prevention; 2024 [cited 2024 2 June]. Available from: https://www.cdc.gov/tobacco/about/?CDC_AAref_Val=https://www.cdc.gov/tobacco/basic_information/health_effects/index.htm

  6. United Nations Development Programme. Investment case for tobacco control in Myanmar: The Case for Investing in WHO FCTC Implementation: United Nations Development Programme. 2018 [cited 2025 16 March]. Available from: https://www.undp.org/sites/g/files/zskgke326/files/migration/mm/Myanmar-Tobacco-Control-Investment-Case.pdf

  7. Le Foll B, Piper ME, Fowler CD, Tonstad S, Bierut L, Lu L, et al. Tobacco and nicotine use. Nat Rev Dis Primers. 2022;8(1). https://doi.org/10.1038/s41572-022-00346-w.

  8. Golechha M. Health promotion methods for smoking prevention and cessation: A comprehensive review of effectiveness and the way forward. Int J Prev Med. 2016;7:7. https://doi.org/10.4103/2008-7802.173797.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Rizvi DS. Health education and global health: practices, applications, and future research. J Educ Health Promot. 2022;11:262. https://doi.org/10.4103/jehp.jehp_218_22.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Esferjani SV, Naghizadeh E, Albokordi M, Zakerkish M, Araban M. Effectiveness of a mobile-based educational intervention on self-care activities and glycemic control among the elderly with type 2 diabetes in Southwest of Iran in 2020. Arch Public Health. 2022;80(1):201. https://doi.org/10.1186/s13690-022-00957-5.

    Article  PubMed  PubMed Central  Google Scholar 

  11. World Bank. Key Findings: Myanmar Living Conditions Survey 2017: World Bank; 2018 [cited 2024 5 January]. Available from: https://www.worldbank.org/en/country/myanmar/publication/key-findings-myanmar-living-conditions-survey-2017

  12. Hsu CD, Momin F, Hess JW, de Carvalho MF. Trends in cigarette smoking prevalence among refinery and petrochemical plant workers, 1950 to 1999. J Occup Environ Med. 2019;61(12):989–95. https://doi.org/10.1097/JOM.0000000000001714.

    Article  PubMed  Google Scholar 

  13. Nematzad P, Pourghane P, Besharati F, Gholami-Chaboki B. Effects of health belief model in promoting self-care behaviors among hypertensive older adults. J Educ Health Promot. 2023;12:208. https://doi.org/10.4103/jehp.jehp_689_22.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Ghorbani-Dehbalaei M, Loripoor M, Nasirzadeh M. The role of health beliefs and health literacy in women’s health promoting behaviours based on the health belief model: a descriptive study. BMC Womens Health. 2021;21(1):421. https://doi.org/10.1186/s12905-021-01564-2.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Angeli M, Hassandra M, Krommidas C, Morres I, Theodorakis Y. Assessing the impact of a health education Anti-Smoking program for students: A Follow-Up investigation. Child (Basel). 2024;11(4):387. https://doi.org/10.3390/children11040387.

    Article  Google Scholar 

  16. Ismail I, Sidiq R, Bustami B. The effectiveness of health education using audiovisual on the Santri smokers’ motivation to stop smoking. Asian Pac J Cancer Prev. 2021;22(8):2357–61. https://doi.org/10.31557/APJCP.2021.22.8.2357.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Deutsch C, Bock BC, Lantini R, Walaska K, Rosen RK, Fava JL, et al. A text message delivered smoking cessation intervention: design and rationale of the text my quit study. Contemp Clin Trials. 2019;81:19–27. https://doi.org/10.1016/j.cct.2019.04.010.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Blomqvist J, Gunnarsson KU, Bendtsen P, Bendtsen M. Effects of a text messaging smoking cessation intervention amongst online help-seekers and primary health care visitors: findings from a randomised controlled trial. BMC Med. 2023;21(1):382. https://doi.org/10.1186/s12916-023-03073-5.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Lin H, Li X, Zhang Y, Wen Z, Guo Z, Yang Y, et al. A randomized controlled trial of personalized text messages for smoking cessation, China. Bull World Health Organ. 2023;101(4):271–80. https://doi.org/10.2471/BLT.22.289051.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Oo MZ, Panza A, Pongpanich S. Prevalence of nicotine dependence among industrial workers in Myanmar. Glob J Health Sci. 2019a;11(3):122–8. https://doi.org/10.5539/gjhs.v11n3p122.

    Article  Google Scholar 

  21. Kyaing NN, Perucic AM, Rahman K, Study on Poverty Alleviation and Tobacco Control in Myanmar: World Bank Group.; 2005 [cited 2024 7 January]. Available from: https://documents.worldbank.org/en/publication/documents-reports/documentdetail/825941468279317733/study-on-poverty-alleviation-and-tobacco-control-in-myanmar

  22. Müssener U, Bendtsen M, Karlsson N, White IR, McCambridge J. Effectiveness of short message service Text-Based smoking cessation intervention among university students: A randomized clinical trial. JAMA Intern Med. 2016;176(3):321–8. https://doi.org/10.1001/jamainternmed.2015.8260.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Li K, Kay NS. Correlates of cigarette smoking among male Chinese college students in China- A preliminary study. IEJHE. 2009;12:59–71.

    Google Scholar 

  24. World Health Organization. Tobacco: Health benefits of smoking cessation: World Health Organization. 2017 [updated 25 February 2020; cited 2018 17 January]. Available from: https://www.who.int/news-room/questions-and-answers/item/tobacco-health-benefits-of-smoking-cessation

  25. Pribadi ET, Devy SR. Application of the health belief model on the intention to stop smoking behavior among young adult women. J Public Health Res. 2020;9(2):1817. https://doi.org/10.4081/jphr.2020.1817.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Müssener U, Linderoth C, Thomas K, Bendtsen M. mHealth smoking cessation intervention among high school students: 3-month primary outcome findings from a randomized controlled trial. PLoS ONE. 2020;15(3):e0229411. https://doi.org/10.1371/journal.pone.0229411.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Dawood OT, Rashan MA, Hassali MA, Saleem F. Knowledge and perception about health risks of cigarette smoking among Iraqi smokers. J Pharm Bioallied Sci. 2016;8(2):146–51. https://doi.org/10.4103/0975-7406.171738.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Alenazi I, Alanazi A, Alabdali M, Alanazi A, Alanazi S. Prevalence, knowledge, and attitude toward substance abuse, alcohol intake, and smoking among male high school students in Riyadh, Saudi Arabia. Cureus. 2023;15(1):e33457. https://doi.org/10.7759/cureus.33457.

    Article  PubMed  PubMed Central  Google Scholar 

  29. FitzGerald JM, Poureslami I, Shum J. Assessing beliefs and risk perceptions on smoking and smoking cessation in immigrant Chinese adult smokers residing in Vancouver, Canada: a cross-sectional study. BMJ Open. 2015;5(2):e006435. https://doi.org/10.1136/bmjopen-2014-006435.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Spek V, Lemmens F, Chatrou M, van Kempen S, Pouwer F, Pop V. Development of a smoking abstinence self-efficacy questionnaire. Int J Behav Med. 2013;20(3):444–9. https://doi.org/10.1007/s12529-012-9229-2.

    Article  PubMed  Google Scholar 

  31. Alanazi AM, Almutairi SF, Alsarami AA, Alanazi FJ, Alqahtani LH, Alotaibi TF, et al. Effects of abstinence Self-Efficacy and outcome expectancies of tobacco smoking on the desire to quit among Saudi women: A Cross-Sectional mediation analysis. Tob Use Insights. 2022;15. https://doi.org/10.1177/1179173X221075581.

  32. Lin LC, Huang CM, Hsu HP, Liao JY, Lin CY, Guo JL. Integrating health literacy into a theory-based drug-use prevention program: a quasi-experimental study among junior high students in Taiwan. BMC Public Health. 2021;21(1):1768. https://doi.org/10.1186/s12889-021-11830-5.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Central Bank of Myanmar. Reference Exchange Rate: Central Bank of Myanmar; 2024 [cited 2024 12 May]. Available from: https://www.cbm.gov.mm/

  34. Howteerakul N, Suwannapong N, Than M. Cigarette, alcohol use and physical activity among Myanmar youth workers, Samut Sakhon Province, Thailand. Southeast Asian J Trop Med Public Health. 2005;36(3):790–6.

    CAS  PubMed  Google Scholar 

  35. Okechukwu CA, Krieger N, Sorensen G, Li Y, Barbeau EM. MassBuilt: effectiveness of an apprenticeship site-based smoking cessation intervention for unionized Building trades workers. Cancer Causes Control. 2009;20(6):887–94. https://doi.org/10.1007/s10552-009-9324-0.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Chinwong D, Mookmanee N, Chongpornchai J, Chinwong S. A comparison of gender differences in smoking behaviors, intention to quit, and nicotine dependence among Thai university students. J Addict. 2018;2018:8081670. https://doi.org/10.1155/2018/8081670.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Oo MZ, Panza A, Pongpanich S. Factors related to intention to quit smoking among industrial workers in Myanmar: A Cross-Sectional study. IJMRAP. 2019b;2(2):1–4. https://doi.org/10.5281/zenodo.3359595.

    Article  Google Scholar 

  38. Gomes da Silva J, Silva CS, Alexandre B, Morgado P. Education as a predictor factor for knowledge of COVID-19 in Portugal. Front Public Health. 2021;9:680726. https://doi.org/10.3389/fpubh.2021.680726.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Reddy UK, Siyo RK, Ul Haque MA, Basavaraja H, Acharya BL, Divakar DD. Effectiveness of health education and behavioral intervention for tobacco de-addiction among degree students: A clinical trial. J Int Soc Prev Community Dent. 2015;5(Suppl 2):S93–100. https://doi.org/10.4103/2231-0762.172949.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Khazaee-pool M, Zarei F, Pashaei T, Shojaeizadeh D. The effect of an educational intervention based on health belief model on improving smoking preventive behaviors among students. Iran J Health Educ Health Promot. 2017;4(4):300–8. https://doi.org/10.18869/acadpub.ihepsaj.4.4.300.

    Article  Google Scholar 

  41. Gharlipour Z, Hazavehei SM, Moeini B, Nazari M, Beigi AM, Tavassoli E, et al. The effect of preventive educational program in cigarette smoking: extended parallel process model. J Educ Health Promot. 2015;4(4). https://doi.org/10.4103/2277-9531.151875.

  42. Sharifi-rad G, Hazavei MM, Hasan- zadeh A, Danesh-amouz A. The effect of health education based on health belief model on preventive actions of smoking in grade one, middle school students. J Arak Uni Med Sci. 2007;10(1):79–86.

    Google Scholar 

  43. Giti A, Shojaeizade D, Heidari G, Khodakarim Ardakani S, Ramezankhan A. The effect of educational intervention based on health belief model on smoking preventive behaviors among female students. J Educ Community Health. 2022;9(3):162–9. https://doi.org/10.34172/jech.2022.24.

    Article  Google Scholar 

  44. Lotfi M, Dostifar K, Dashtban M, Kassiri H. A study on the effect of education based on the health belief model on male smoking students in reducing cigarette smoking in Ahvaz Jundishapur university of medical sciences, Ahvaz, Iran (2009–2010). Biomed Pharmacol J. 2016;8(4):380–9.

    Google Scholar 

  45. Khani Jeihooni A, Mobaraei A, Kiani A, Afzali Harsini P, Karami Ghazi Khani S. The effect of the educational intervention on empowerment of male high school students in prevention of smoking. J Subst Use. 2021;27(2):162–7. https://doi.org/10.1080/14659891.2021.1916844.

    Article  Google Scholar 

  46. Rafiee Z, Assarroudi A, Zare M, Heidarian Miri H, Behboudifar A, Heshmati Nabavi F. Effects of a School-Based interventional program on smoking refusal Self-efficacy in adolescent females. Evid Based Care J. 2018;8(3):46–56. https://doi.org/10.22038/ebcj.2018.32995.1835.

    Article  Google Scholar 

  47. Andrade C. The limitations of quasi-experimental studies, and methods for data analysis when a quasi-experimental research design is unavoidable. Indian J Psychol Med. 2021;43(5):451–2. https://doi.org/10.1177/02537176211034707.

Download references

Acknowledgements

We express our gratitude to the industrial workers who participated in this study. Additionally, we would like to thank the management of each industry and the Industrial Zone Committee for permitting us to conduct the study. We also acknowledge the support provided by Chulalongkorn University, the National Research Council of Thailand, and Chiang Mai University, Thailand.

Funding

The authors received no funding for the research.

Author information

Author notes

  1. Myo Zin Oo and Soe Sandi Tint contributed equally as co-first authors of this work

Authors and Affiliations

  1. Environmental - Occupational Health Sciences and Non Communicable Diseases Research Center, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, 50200, Thailand

    Myo Zin Oo & Kittipan Rerkasem

  2. Global Health and Chronic Conditions Research Center, Chiang Mai University, Chiang Mai, Thailand

    Soe Sandi Tint

  3. Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

    Soe Sandi Tint

  4. College of Public Health Sciences, Chulalongkorn University, Bangkok, Thailand

    Alessio Panza, Sathirakorn Pongpanich, Pramon Viwattanakulvanid & Somdeth Bodhisane

  5. Research Center for Infectious Disease and Substance Use, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand

    Amaraporn Rerkasem

  6. Clinical Surgical Research Center, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

    Kittipan Rerkasem

Authors
  1. Myo Zin Oo
    View author publications

    You can also search for this author inPubMed Google Scholar

  2. Soe Sandi Tint
    View author publications

    You can also search for this author inPubMed Google Scholar

  3. Alessio Panza
    View author publications

    You can also search for this author inPubMed Google Scholar

  4. Sathirakorn Pongpanich
    View author publications

    You can also search for this author inPubMed Google Scholar

  5. Pramon Viwattanakulvanid
    View author publications

    You can also search for this author inPubMed Google Scholar

  6. Somdeth Bodhisane
    View author publications

    You can also search for this author inPubMed Google Scholar

  7. Amaraporn Rerkasem
    View author publications

    You can also search for this author inPubMed Google Scholar

  8. Kittipan Rerkasem
    View author publications

    You can also search for this author inPubMed Google Scholar

Contributions

MZO, KR, AP, and SP involved in conceptualization and methodology. MZO, AP, and SST involved in implementation. MZO, SST, PV, AR and SB contributed in data curation, formal analysis, data interpretation. MZO and SST wrote the original draft. KR, AP, SP, AR involved in review and editing. All authors confirmed the final version of the manuscript.

Corresponding author

Correspondence to Kittipan Rerkasem.

Ethics declarations

Ethical approval

This study obtained ethical approval from the Research Ethics Review Committee for Research Involving Human Research Participants, Health Sciences Group, Chulalongkorn University (COA number 086/2018), and was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained after participants were informed of the study’s risks and benefits. While formal ethical review mechanisms are available in Myanmar, this study was conducted as part of the first author’s doctoral research at an academic institution in Thailand. Given the non-clinical nature of the intervention and the institutional affiliation, ethical approval was obtained from the university’s recognized ethics committee in Thailand. A meeting was organized with the township’s general administrative department, health department, industrial zone management committee, industry (company) owners and managers, and the Directorate of Investment and Company Administration (DICA), Mandalay Region, to explain the study and ensure compliance with local regulations, cultural norms, and legal requirements, which are critical to the ethical conduct of research. Following the meeting, verbal permission to conduct the study was granted by all these relevant authorities. After the study, the findings were also interpreted back to these authorities to ensure transparency and collaboration. Additionally, prior coordination with the Mental Health Hospital in Mandalay under the Ministry of Health ensured support for participant well-being, with arrangements for referral if needed; however, no participants required clinical referral during the study. At the time of the study, two Myanmar citizen authors, who worked within non-governmental organizations, led the project and liaised with local stakeholders. They were directly involved in executing the research, with the collaboration of co-authors further strengthening oversight throughout the process. The research upheld key ethical principles, including anonymity and confidentiality, voluntary participation, freedom to withdraw, access to findings, and data protection, ensuring a comprehensive approach to ethical standards and privacy.

Patient consent for publication

Not applicable.

Provenance and peer review

Not commissioned; externally peer reviewed.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Oo, M.Z., Tint, S.S., Panza, A. et al. Effectiveness of a Health Belief Model-based integrated health education and mobile phone short message service intervention on health knowledge, perception, and self-efficacy toward smoking: a quasi-experimental study among industrial workers in Myanmar. BMC Public Health 25, 1562 (2025). https://doi.org/10.1186/s12889-025-22754-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12889-025-22754-9

Keywords

BMC Public Health

ISSN: 1471-2458

Contact us