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1 ANTECEDENTS AND CONSEQUENCES OF NICOTINE DEPENDENCE AND…

OUR LADY OF FATIMA COLLEGE OF NURSING

Antecedents and Consequences of Nicotine Dependence and Readiness to Quit

among Student Smokers of the Allied Health Programs in the Philippines

Jade P. Mojica1,2,3, John Gerald A. Calisay1,2,3, Jason M. Franco1,2,3, Owoh Joshua

Amobi1,2,3 Vikhuli Hansen1,2,3, Jenica A. Rivero1,2,3,4

1College of Nursing

2Research Development and Innovation Center

3Our Lady of Fatima University

4Research Adviser

October 2015



Endorsement

This research entitled “Antecedents and Consequences of Nicotine Dependence

and Readiness to Quit among Student Smokers of the Allied Health Programs in the

Philippines” prepared by Jade P. Mojica et al. of section 4Y1-1, in partial fulfillment of the

requirements for the degree Bachelors of Science in Nursing has been examined and now

recommended for Oral Examination.

This is to certify that Jade P. Mojica et al. are ready for the Oral Examination.

Jenica A. Rivero

Adviser

This is to certify that the thesis: “Antecedents and Consequences of Nicotine

Dependence and Readiness to Quit among Student Smokers of the Allied Health Programs

in the Philippines” prepared and submitted by Jade P. Mojica et al. of section 4Y1-1, is

recommended for Oral Examination.

Christian V. Del Rosalio

Chair

Caesardo A. Nicolas RN, MAN Shawn B. Cajayan RN, MAN

Member Member

Lurceli L. Santos MAN, RN, RM

Dean, Our Lady of Fatima University



Certificate of Originality

We hereby declare that this thesis is our own work and that, to the best of our knowledge

and belief, it contains no material previously published or written by another person nor

material to which to a substantial extent has been accepted for award of any other degree

or diploma of a university or other institute of higher learning, except where due

acknowledgement is made in the text.

We also declare that the intellectual content of this thesis is the product of our work, even

though we may have received assistance from others on style, presentation and language

expression.

Jade P. Mojica

Principle Investigator

Members:

John Gerald A. Calisay

Jason M. Franco

Owoh Joshua Amobi

Vikhuli Hansen

Jenica A. Rivero RN, MAN

Adviser

Date



Table of content

Endorsement 2

Certificate of Originality 3

List of Tables 6

List of Figures 7

List of Appendices 8

Abstract 9

1.0 Introduction 10

2.0 Literature Review 11

2.1 Theoretical Framework 11

2.2 Variable Discussion 12

2.2.6 Problem Statement and Hypothesis 15

2.3 Research Simulacrum 17

3.0 Research Methods 17

3.1 Research Design 17

3.2 Research Locale 18

3.3 Population and Sampling 18

3.4 Research Ethics 18

3.5 Research Instrument 19

3.6 Data Collection 20

3.7 Data Analysis 21

4.0 Results 21

4.1 Demographic Profile of the Respondents 21

4.2 Nicotine Dependency, Intention to Quit, and Health Related

Quality of Life

23

4.3 Demographic Difference on Nicotine Dependency 24

4.4 Demographic Differences on Readiness to Quit 25

4.5 Impact of Nicotine Dependency to Health Related Quality of life 26

4.6 Impact of Readiness to Quit on Health Related Quality of Life 27

5.0 Discussion 28

6.0 Conclusion 33



7.0 Recommendation 34

Reference 35

Appendices 39

Acknowledgement 52



List of Tables

Table 1 Demographic Profile of the Respondents 22

Table 2 Nicotine Dependency, Readiness to Quit, and Health Related Quality

of Life

23

Table 3 Demographic Differences on Nicotine Dependency 24

Table 4 Demographic Differences on Readiness to Quit 25

Table 5 Impact of Nicotine Dependency on Health Related Quality of Life 27

Table 6 Impact of Readiness to Quit on Health Related Quality of Life 27



List of Figures

Figure 1 Research Simulacrum 17



List of Appendices

Appendix A: Ethics Approval 39

Appendix B: Permission to Use Questionnaire 40

Appendix C: Consent 41

Appendix D: Questionnaire 42

Appendix E: Fagerstrom Test of Nicotine Dependency 43

Appendix F: Quit Ladder 44

Appendix G: EQ-5D-5L 45

Appendix H: Statistics Certificate 47

Appendix I: Budget 48

Appendix J: Timeline 49

Appendix K: About the Researchers 50



Abstract

Smoking is associated with most of the health related condition worldwide, and which this

research is done to elicit the level of nicotine dependency, readiness to quit, and the

perception of smoking related to age, health related quality of life, social acceptance, socio

economic, gender and religion. Consequences of Nicotine Dependence and Readiness to

Quit was conducted in a tertiary institute with a corresponded of 262 in Valenzuela city,

Philippines. We conducted a quantitative and descriptive correlational study on the student

smokers in the Allied Health Programs in the Philippines. It helps show a relation between

4 fields of study; demographic, nicotine dependency, readiness to quit, and health related

quality of life. The study is based on a target population of 262 college student smokers

who are enrolled for the school year 2015-2016 in a Higher Educational Institution in the

Philippines. Pearson’s correlation shows that there’s a weak negative association between

the readiness to quit smoking and level of pain/discomfort (r=-0.146, p-value=0.018; and

between readiness to quit smoking and anxiety or depression (r=-0.247, p-value<0.001)

which are both statistically significant. However, weak negative association but not

statistically significant were observed between readiness to quit smoking and mobility (r=-

0.059, p-value=0.338); self-care (r=-0.059, p-value=0.344) and usual activities (r=-0.099,

p-value=0.11). Pearson’s correlation shows that there is significant association between the

nicotine dependency and health related quality of life namely mobility, self-care and

pain/discomfort. There is a weak inverse relationship between nicotine dependency and

mobility (r=0.141, p-value=0.022). Nicotine dependency and self-care(r=0.152, p-

value=0.014) and nicotine dependency and pain/discomfort (r=0.145, p-value=0.019).

Nevertheless, result shows that there is weak positive association between nicotine

dependency and usual activities(r=0.05, p-value=0.423) and nicotine dependency and

anxiety/discomfort (r=0.094, p-value=0.128) which both not statistically significant.

Keywords: Nicotine Dependence, Age, Religion, Socio-economic, Gender, Cigarette

Smoking, Intention to quit smoking, college student, cigarette, nicotine.



1.0 Introduction

The increase in tobacco smoking through the use of cigarette remain one of the

most significant causes of preventable diseases worldwide. Health related quality of life is

decreased in people who are more nicotine dependent compared to others who are less

nicotine dependent, despite the understanding of the negative health effect associated with

smoking, some people still continue to smoke as long as the cigarette meet there pleasure

need and ignoring the negative effect of respiratory problem, metabolic problem, malignant

problem and other ill health associated with smoking. The negative effect of smoking does

not begins to manifest on one’s health immediately, rather it gradually destroys the normal

cell of vital organs in the human body resulting to latter life organ impairment and

sometime manifest early in middle life.

Smoker’s perception and lifestyle is an aspect to systematically evaluate the habit

of smokers, and their readiness to quit smoking. Some people who smoke more cigarette

per day find it more difficult to quit compare to those who smoke occasionally because the

more dependent a person is to nicotine the more he or she crave to smoke compared to

those who smoke occasionally. Some occasional smokers have not yet reach the peak of

craving, so there will stand a better chance to quit compare to a chronic smoker who is

already dependent to it.

Most developing countries have started to combat the rate at which their citizen

smoke through the use of media awareness of the associated negative health and evaluating

their readiness to quit smoking. Readiness to quit could be associated with the perceived

negative health of the individual or due to medical diagnosis as a motivation to quit

smoking. Religion also could be motivation to cigarette cessation because of the

steadfastness in religious practice and activity which one is associated with in daily life.

the more close one is to his religious practice will gradually reduce the consumption of

cigarette per day and gradually stop smoking even when religion do not generally prohibit

the use of tobacco else 80 to 90 % of the world population will be free from most of the

diseases caused by the use of tobacco product through the smoking of cigarette.

In gender and social acceptance related to cigarette smoking, Gender is commonly

seen with as stereotyping attitude which male are accepted to smoke while female smokers



are seen as inappropriate. Socio acceptance of female smokers is marred with wildness and

unsuitable to some people despite that female smokers are known to be occasional smokers

compared to male smokers who are habitual smokers. Female smokers commonly smoke

for the fun of it or trying to create a gesture of belongingness in an environment where

mostly everyone smokes so as not to be left out. Nevertheless, female smokers who smoke

as the same quantity as male are twice dependent to nicotine than men, and will find it

more difficult to quit.

2.0 Literature Review

2.1 Theoretical Framework

Two theories was used to describe the study framework. These theories are Dorothy

Johnson’s Behavioral Systems Theory and Albert Bandura’s Self-Efficacy theory. The

Behavioral Systems theory allows the giving of efficient and effective behavioral

functioning in the patient to prevent illness. While the Self-Efficacy theory explains the

change of human behavior, both theories are patient centered and based on behavior.

Dorothy Johnson’s Behavioral System Theory. This theory gives more importance

on the connection of the patient to the environment than the patient to environment alone.

“The patient is identified as a behavioral system composed of seven subsystems:

attachment, dependency, ingestion, eliminative, sexual, aggression, (Gonzalo. A). the

subsystems are interrelated, meaning that if one is altered then the other subsystems will

also be altered. According to Johnson “each of the behavioral subsystems are influenced

by events in the environment” (Octaviano & Balita). Johnson focuses on two areas, “first,

nursing care should lessen stimuli that are stressors, and second, nursing care should offer

support of the client’s normal defenses and adaptive processes” (Octaviano & Balita).

Albert Bandura’s Self-Efficacy Theory. This theory focuses more on changing

behavior of a person’s perception of their ability to reach a goal. “Self-efficacy beliefs



provide the foundation for human motivation, well-being, and personal accomplishment”

(Pajares, F.). Self-efficacy explains the change of human behavior.

These both support our study because they are both patient centered and based on

the behavior. The study is about factors relating to smoking cessation, whereas quitting is

a decision made by the individual. In Bandura’s theory, he studied the way behaviors

change, such as the research question used, what influences college students to quit?

Johnson’s Behavioral Theory states that if one subsystem is altered, the others will be

altered. This research is not trying to elicit the reason why college student smoke but rather

to understand if there are some reason or effort put in place to quit smoking, also, to

ascertain the level of nicotine dependency among the participant of the research.

Variable Discussion

2.2 Literature Review

The research conducted used a descriptive correlational nonexperimental method.

The variables that were examined include age, religion, socioeconomic status, heavy

smoking, and health issues relating to quitting smoking. We believed that these variables

would important in influencing smokers to either quit or continue smoking.

2.2.1 Age

The relationship of Age to nicotine dependency is a characteristics that cannot be

undermine because age stand as the quantitative aspect of human development, and at some

time in life where curiosity is heightened one will tend to explore the world he lives in, and

the good and bad that goes with it. Hence cigarette consumption will come into exploration.

The increase in cigarette dependency is commonly seen in teenagers of 19 years and above

when anxiety and exploration play more role to cigarette consumption to sometime in

middle adulthood of 25 to 27 years old when decision making has started to set in. These

put some young adult in pressure and depression to relieve themselves with a puff of a stick

or two to more in the subsequent days.



Young adults are majority of college students in most country in the world today, and the

increased in cigarette consumption are commonly seen among this set of individuals.

Smoking rates are declining in the United States, except for young adults (age 18 to 24)

(Ling 2004.). In a study, it was found that there is an increase in smoking prevalence from

adolescence to young adulthood and then a decline after the mid 20's (Paavola 2000.). This

study was conducted on the same group when they were 14 years, 20 years, and 27 years

to compare the difference in smoking. They were able to find that the desire to quit does

not differ much among different age groups. In all age groups one tenth of smokers want

to continue smoking and half of smokers would like to quit (Paavola 2000.) In a study

about tobacco industry recapturing young adults concluded that in 1986 many of the

smokers most likely to quit, such as intermittent smokers or brand switchers, were young

adults (Ling 2004.) Also that, tobacco companies attempted to recapture younger quitters

by developing products that appeared to be less addictive or more socially acceptable. This

suggests that smoking menthol cigarettes are popular among young adults, making it more

difficult to successfully quit (Fagan 2007.). With a large increase in smoking among the

young adults this also be the hypothesis for our research.

2.2.2 Religion

The Relationship between Religious Activities and Cigarette Smoking in Older

Adults has concluded that religiously active people were less likely to smoke cigarettes. If

the religious person does smoke they smoke fewer than those less religiously active. Those

who never attended religious activities had a higher percentage of smoking and a higher

amount of pack per year. This is compared to the people who attend religious activities

more than 1 times a week who have a low percentage of smokers. For those who do smoke

they have a lower amount of packs smoked per year.

2.2.3 Socioeconomics



Socioeconomics is a factor that hasn’t adequately been assessed in most studies

(Siahpush 2004.). But even then, it can be a predictor of smoking cessation when actually

being assessed. There is an increasing prevalence of smoking with a decreasing

socioeconomic status (Gilman 2003.). In a study it was observed that socioeconomically

disadvantaged smokers find quitting more difficult, possible because lack of support for

quit attempts, greater addiction to tobacco, less motivation to quit and less compliance to

treatment (Hiscock 2010.). This lack of support has been identified as a reason for low quit

rates among disadvantaged smokers (Hiscock 2010.). These disadvantaged smokers are

most commonly in developing countries making it difficult to quit among these countries.

2.2.4 Nicotine Dependency

Nicotine addiction is believed to be a major impediment for many people in quitting

smoking, but measures of nicotine dependence such as the heaviness of smoking index

have mixed success in predicting cessation. The level of nicotine dependence is important

in assessing the effectiveness of smoking prevention and control programs. There are

several scales available for measuring addiction level such as the Fagerstrom tolerance of

nicotine dependence, the cigarette dependence scale, and the nicotine dependence scale. A

study in Canada found that heaviness of smoking index is associated with reported changes

in smoking. The result of this study says smokers who had low heaviness of smoking index

scores quit earlier than those with higher score but the long term cessation rates were

similar (Kozlowski 1994) more like quitting smoking at follow-up. But the data did not

indicate a constant relationship between increasing heaviness of smoking index scores and

a decreasing probability of cessation at follow-up. In this study people with low levels of

nicotine dependence as measured by heaviness of smoking index consistently to report

quitting, highly nicotine dependent smokers, particularly older and wealthier also reported

a substantial likelihood of cessation. Other research found that for the majority of smokers,

dependence is only one factor in making, and succeeding to quit attempt with cognitive,

affective, and environment influences being other important factors (McDonald 2003;

Kenford t al., 2002).



The heaviness of smoking can be considered the degree to which an individual is

attached to cigarette smoking, this conception of dependence only partially related to actual

chances of quitting. The affective model of nicotine dependence is related to individual

capacity to experience negative affect and an individual’s expectations that quitting

nicotine would improve this effect, is a better predictor of smoking cessation.

There is increasing recognition that the two measures in the heaviness of Smoking

Index, time to first cigarette of the day and daily consumption (cigarettes per day), are

strongly predictors of quitting behavior. Study found out that both time to first cigarette of

the day and cigarettes per day are fairly reliable and important predictors of quitting

outcomes. The study demonstrate that the categorical scoring method adequate for many

purposes. One of the advantage in relative meaning of consumption changes as a result of

reduced opportunities to smoke (e.g., result of smoke-free policy; Husten, 2009)

2.2.5 Health Related Quality of Life

Several decades of research have established the causal relationship between

tobacco smoking and a variety of adverse health effects. The health benefits of smoking

cessation include a reduction of the risk of lung and other cancers, heart attack, stroke, and

chronic lung disease. The dynamics of smoking cessation are complicated, and the struggle

to quit permanently can be prolonged, involving several attempts (and relapses) before

permanent cessation is achieved. As well, it may take years of abstinence for disease risk

to be similar to that of people who never smoked. Therefore, research aimed at studying

the relationship between smoking status and health outcomes by using the EQ-5D-5L a

generic preference-based measure that reflects the subjective values assigned to specific

health-related outcomes was to assess health-related quality of life and outcomes.

2.2.6 Problem statement and hypothesis

Cigarettes smoking is one of the most recognized cause associated with different

kind of health related problem around the world ranging from metabolic diseases,



respiratory and malignant diseases. The problem statement of the research is identifying

whether if health related quality of life of individual smokers has a relationship to why the

correspondents decide to quit smoking cigarette, this research is made to believe that

anyone who is suffering from a health condition whereby smoking of cigarette will

exacerbate the condition of the individual might want to consider quitting smoking.

Religion in the other hand might have a significant relationship to why anyone would

consider to quit smoking even though religion does not entirely prohibit the use of cigarette

but still value human existence and as such will encourage cessation. Social acceptance is

another aspect to the relationship to why smoking cessation is encourage to most people,

if in a group of friends and only one person smokes, the influence of the other friends who

perceive cigarette as a bad habit or practice that might give the smoking friend the

perception that the other friends are not always comfortable when he is around them and

might be the significant relationship to smoking cessation. In some research, smoking

cessation related to nicotine dependence show some significant relationship to quitting in

accordance to the heaviness of cigarette smoking, and so as in social acceptance. Socio

acceptance related to smoking is the stereotyping associated with practice or behavior that

is unacceptable to others and as such will deem it inappropriate as perceived by the people

who feel affected or in close contact with primary perpetrator of the perceived

inappropriate character.

Hypothesis

1) How does demographic differences relate to nicotine dependence and readiness to quit?

2) What is the impact of nicotine dependency to health related quality of life?

3) What is the impact of readiness to quit to health related quality of life?

i. We believe that, age, sex, religion and Social Economics is another significance

that could enhance the readiness to quit smoking cigarette due to low financial

status or not having enough to spare for a stick of cigarette or more compare to

quantity per day and how low socioeconomic increase the rate of smoking and

dependence to nicotine.



ii. Nicotine dependency to health related quality of life is another significance that we

believe will have a relationship to readiness to quit smoking due to the health

related perception of chronic smoking.

iii. The researchers believe that there will be significance with readiness to quit

smoking and Heath Related Quality of Life among the smoking correspondent.

2.3 Research Simulacrum

Figure 1. Research Simulacrum

3.0 Research Methodology

3.1 Research design

The design used for the research was a quantitative approach, and descriptive

correlation. This design uses the dependent variables and independent variables to find a

relationship of the data. This was done by self-evaluation through the use of questionnaires

for the correspondent to provide information regarding steps taking to quit smoking and



the motivating factors regarding their decision, or they don’t have the intention to quit, of

which shows how dependent they are to nicotine, also, the method used will help show the

quantity of cigarette consumption per day, and the onset of smoking from getting up from

bed in the morning.

3.2 Research locale

The research was carried out in a tertiary institution and one of the many

universities with the most accredited courses in the Philippines. It is an ISO certify school

and one of the few university granted the right to offer medical courses, and with a level

four (LEVEL 4 PACUCOA) accreditation in nursing in the Philippines. The institution is

located in Manila. It comprises of five section of the campus that possess the different

colleges, and the main campus comprises the allied health programs where the data was

collected.

3.3 Population and sampling

In order for the respondent to participate he/she must have the following

characteristics; be of age meaning 19 years or older, currently enrolled in an HEI in NCR

as a student of the Allied Health Program, and must be of sound mind without any

neurologic disorders. This is to prevent errors and incorrect input into the research data.

Our sampling technique used was a snowball sampling to prevent violation of individual

confidentiality. After the respondent participates in the question we asked them if they may

refer us to other smokers that also fit the characteristics of our target population.

3.4 Research Ethics

This research paper went through review with the ethics committee of the

University and was approved before the research was conducted. The research also

obtained an informed consent from every participant to ensure their knowledge of the

research and to help clarify their understanding that their participation is voluntary with no



benefits or losses. Confidentiality and anonymity is ensured that no harm will be brought

upon the participant, and if the participant feels the need or desired to stop even after they

might have attempted the question on the questionnaire, they may do so without any

penalties.

3.5 Research instruments

Demographics. The questionnaire is divided into 4 sets of questions; 1demographic

profile, 2currently smoking, 3quitting smoking, and 4have already quit. The demographic

profile consists of five significance; age, gender, religion, socio economic status, and

education attainment. Currently smoking asks how long the participant has been smoking,

how many sticks they smoke per day, and how soon after they wake they smoke. The

quitting smoking set asks the participants if they want to quit, how many times they had

tried, how long they have abstained from smoking, and what they think is the one most

important reason they would quit smoking. The last section of the questionnaire is for those

participants who have already quit smoking. It asks how long they have quit smoking and

if they are tempted to start again. The purpose of this questionnaire is to explore their

history in smoking and desire to quit.

Fagerstrom Test for Nicotine Dependence (FND). The Fagerstrom Test is an

instrument used to measure the participants’ dependency to nicotine by asking six different

questions. These questions includes how soon is it to the smoker’s first cigarette, if they

have difficulty to refrain from smoking, which they would not like to give up, how many

sticks per day, if they smoke more frequently in the first hour of the day or any other time,

and if they smoke even if they are ill. Each answer choice has a score that would be added

to find the outcome of the test which can be low, low to moderate, moderate, or high. This

test has been used in other researches to measure smoker’s dependency for after they quit.

It helps to indicate the appropriate treatment for withdrawal symptoms in certain

researches. If the participants score between 1-2 they have a low dependency to nicotine.

A score of 3-4 indicated low to moderate, 5-7 indicates moderate level, and 8 or high is

considered high dependency.



Quit Ladder. The Readiness to Quit Ladder is a 1-10 scale that provides statements

or thoughts that the smoker may have to indicate their readiness to quit tobacco smoking.

This tool was created to help know when the appropriate time to start treatment. If the

smoker chooses 7, “I definitely plan to quit smoking in the next 30days,” treatment would

be best to start. The individual’s readiness may change over time meaning those who

indicate they do not want to quit may later want to quit and those who say they are ready

may later not want to quit anyone. In other research, treatment are applied to such

individual to help them reframe from smoking, but this research does not subject the

participant to any treatment to stop smoking, rather, it evaluate the participant level of

dependent to cigarette smoking and the factors which may cause the individuals readiness

to quit

EQ-5D-5L. The EQ-5D-5L is a European questionnaire that has 5 dimensions;

mobility, self-care, usual activities, pain/ discomfort, and anxiety/ depression. Within these

dimensions there are 5 different statements or levels which includes no, slight, moderate,

severe, and unable or extreme. This instrument is used for the individual to rate his health

on the current day. The second part of the tool is a scale of 0-100 with 100 being the best

health imaginable and 0 meaning the worst health imaginable. This perception of their

health is also for the current day. This questionnaire was used for this study to evaluate the

participants health related quality of life.

3.6 Data Collection

Before the study was carried out, the researchers went through the University’s

research department for review and ethical approval to prevent any errors in the paper. Data

was collected by explaining the goal of the study to the participants and making sure that

participation is voluntary. Afterword, the questionnaire was given to the participant

together with a consent form to be signed with their name printed as a sign of approval.

Any questions asked by the participants were well explained to prevent error in data

gathering. As soon as they completed all section of the questionnaire, we kindly asked the



participants if they had anyone they may refer us to that fits the characteristics of our target

goal and so doing, prevent public embarrassment of our participants.

3.7 Data Analysis

For analyzing the data the T-Test and Analysis of Variance (ANOVA) was used to

compare the difference between the variables. T-Test is an analysis that uses 2 groups to

be compared most commonly used when the data findings are considered categories. In

analysis of variance, it uses more than two groups that are numerically scaled. For example,

in our research when we compare the difference of the sexes we use the T-Test, but when

we compare the impact of nicotine dependence to health related quality of life we use the

ANOVA because each score is a numeric value. Pearson correlation was used to compare

the strength and the weakness of the variables, the level of significant was set 0.05 to accept

result less than the level of significance, and any valur above the level of significance was

rejected.

4.0 Results

4.1 Demographic Profile of the Respondents

Table 1 presents the demographic profile of the respondents. Majority of the

respondents are 19 to 21 years old, males, middle class, Roman Catholic and in the

undergraduate level.

This might seem strange to some readers but it is the reality that most people do not

understand what is Christianity and the denominated churches under Christian doctrine in

the Philippines. Roman Catholic Church is a denomination under Christianity. In the

Philippines, most people believe that Christian is a religion where the people are born again

and differ from Roman Catholic Church as well as Iglesia Ni Christo Church. So when you

say that you are a Christian most people take you for a born again. Example of a born again

person in the Philippines, you are a member of Victory Church, Redeem Christian Church,

and if you are a Roman Catholic you are not a Christian but just only a Roman Catholic.



Although, there are few who understand what is Christianity and the denomination of

Christians. To prevent confusion or try to explain what might lead to a debate and distract

us from our intended goal, we made a questionnaire which have Christian, Roman Catholic,

Iglesia Ni Cristo, and others____ in the religious section of Christianity and must only

choose one of the giving or write the name of their denomination if it was not giving.

Table 1

Demographic Profile of the Respondents (n=262)

Demographic Profile f %

Age interval

19-21 130 49.6

22-24 73 27.9

25-27 43 16.4

28-30 11 4.2

31yrs or older 5 1.9

Gender

Female 82 31.3

Male 180 68.7

Religion

Agnostic 1 0.4

Atheist 5 1.9

Buddhist 1 0.4

Hindu 15 5.7

Muslim 12 4.6

Christian 52 19.8

Roman Catholic 159 60.7

Iglesia Ni Cristo 15 5.7

Methodist 1 0.4

Protestant 1 0.4

Socio-economic



high 8 3.1

low 7 2.7

middle 131 50

no response 116 44.3

Educational Attainment

undergrad 171 65.2

grad school 45 17.2

no response 46 17.6

4.2 Nicotine Dependency, Intention to Quit and Health Related Quality of Life (HRQoL)

(n=262)

Table 2 presents the mean score of the participants’ nicotine dependency which is

low to moderate, readiness to quit which is 7 meaning a plan to quit in 30days, and health

related quality of life which has no problem in all five dimensions.

Table 2

Nicotine Dependency, Intention to Quit and Health Related Quality of Life (HRQoL)

Continuous Variables Mean SD VI

Nicotine Dependency 3.02 2.12 A score of 3 mean low-

moderate dependent to nicotine

Readiness (quit ladder) 6.82 2.08

A score of 6 means there is a

plan to quit in the next

6months

A score of 7 means there is a

plan to quit in the next 30

days

Mobility 1.18 0.46 No problem



Self-Care 1.16 0.53 No problem

Usual Activities 1.27 0.61 No problem

Pain/ Discomfort 1.31 0.58 No problem

Anxiety/ Depression 1.46 0.82 No problem

Range for HRQoL: 1.0 -1.49 No problem; 1.5-2.49 Slight problem, 2.5-3.49 Moderate

problem, 3.5 – 4.49 Severe problem, 4.5 – 5.0 Extreme Problem

4.3 Demographic Differences on Nicotine Dependency

Table 3 shows that no significant difference exist in the nicotine dependence of the

respondents when grouped according to age, religion, social class, and educational

attainment. However, a significant difference exists when respondents are grouped

according to gender (p=0.048).

Table 3

Demographic Differences on Nicotine Dependency

Demographic vs Nicotine

Dependency mean(SD)

test

statistic p-value interpretation

age interval(n=257)

19-21yrs 2.99(2.06)

F=0.414 0.743 no difference 22-24yrs 2.93(2.06)

25-27yrs 3.21(2.26)

28-30yrs 2.45(2.16)

gender(n=262)

female 3.4(2.21) t=1.989 0.048

with

difference male 2.84(2.06)

religion(n=258)

Roman catholic 3.04(2.05) F=0.35 0.93 no difference

Muslim 3.17(2.29)



Christian 2.81(2.13)

Hinduism 2.87(2.39)

INC 3.33(2.41)

Atheist 3.6(2.70)

socio-economic status(n=146)

low 2.14(1.46)

F=0.498 0.609 no difference middle 2.85(2.06)

high 3.13(1.81)

educational attainment (n=216)

undergrad 3.01(2.15) t=0.948 0.344 no difference

grad school 2.67(2.06)

*significant at 0.05

4.4 Demographic Differences on Readiness to Quit

It can be seen on Table 4 that there is no significant differences between

demographic differences on readiness to quit, namely age, gender, socioeconomic status,

and educational attainment. Yet, in religion there is a significant in readiness to quit

(p=0.046).

Table 4

Demographic Differences on Readiness to Quit

Demographic vs readiness to

quit mean(SD)

test

statistic p-value interpretation

age interval(n=257)

19-21yrs 7.08(2.09)

F=1.312 0.271 no difference 22-24yrs 6.60(2.08)

25-27yrs 6.70(2.09)

28-30yrs 6.18(1.89)

gender(n=262)

female 6.91(2.06) t=0.473 0.637 no difference



male 6.78(2.10)

religion(n=258)

Roman catholic 6.92(1.91)

F=2.083* 0.046 with

difference

Muslim 6.67(2.54)

Christian 6.96(2.260

Hinduism 7.0(1.69)

INC 6.1392.450

Atheist 6.2(2.07)

socio-economic status(n=146)

low 7.29(1.70)

F=0.345 0.709 no difference middle 6.91(1.91)

high 7.38(1.69)

educational attainment (n=216)

undergrad 6.87(2.12) t=0.143 0.886 no difference

grad school 6.82(1.74)

*significant at 0.05

4.5 Impact of Nicotine Dependency to Health Related Quality of Life (HRQoL)

Table 5 presents that there is significant association between the nicotine

dependency and health related quality of life namely mobility, self-care and

pain/discomfort. There is a weak inverse relationship between nicotine dependency and

mobility (r=0.141, p-value=0.022) This could probably be that the correspondent do not

experience any discomfort because that there are still in the early stage of smoking and

have not yet experience the impact of health problem associated to nicotine dependence,

Nicotine dependency and self-care(r=0.152, p-value=0.014) and nicotine dependency and

pain/discomfort (r=0.145, p-value=0.019).

However, result shows that there is weak positive association between nicotine

dependency and usual activities(r=0.05, p-value=0.423) and nicotine dependency and

anxiety/discomfort (r=0.094, p-value=0.128) which both are not statistically significant.



Table 5

Impact of Nicotine Dependency to Health Related Quality of Life (HRQoL)

Quality of Life R p-value Interpretation

Mobility 0.141* 0.022 significant( weak positive)

Self-care 0.152* 0.014 significant(weak positive)

Usual activities 0.05 0.423 not significant

Pain/Discomfort 0.145* 0.019 significant(weak positive)

Anxiety/Depression 0.094 0.128 not significant

* Correlation is significant at the 0.05 level

4.6 Impact of Readiness to Quit to Health Related Quality of Life (HRQoL)

Table 6 shows that there’s a weak negative association between the

readiness to quit smoking and level of pain/discomfort (r=-0.146, p-value=0.018; and

between readiness to quit smoking and anxiety or depression (r=-0.247, p-value<0.001)

which are both statistically significant.

However, weak negative association but not statistically significant were observed

between readiness to quit smoking and mobility (r=-0.059, p-value=0.338); self-care (r=-

0.059, p-value=0.344) and usual activities (r=-0.099, p-value=0.11).

Table 6

Impact of Readiness to Quit to Health Related Quality of Life (HRQoL)

Quality of Life r p-value Interpretation

Mobility -0.059 0.338 not significant

Self-care -0.059 0.344 not significant

Usual activities -0.099 0.110 not significant

Pain/Discomfort -.146* 0.018 significant (weak negative association)



Anxiety/Depression -0.247* 0.000 significant (weak negative association)

* Correlation is significant at the 0.05 level

5.0 Discussion

5.1 Table 1

The age relationship of increased smoking is mostly found among young adult of

age 19 to 21 years old and middle adult 25 to 27 shows the increased of nicotine

dependence according to the collected data, this is possibly that the increased result of

nicotine dependence among young adult of 19 to 21 years old could be associated to the

their young intuitive age were exploring is mostly common and as such will want to get

the feeling and experience of smoking. Contrast to the middle age group were increased

dependence of nicotine was found could lead to result of depression which is mostly

common to young adult of this age group possibly due to the fact that this is the stage of

young adult to adult life where decision making is common. In other studies young adults

are found to be majority of the smoking population. In agreement to our findings, young

adults are found to be most of the smoking population in the United States and Canada due

to the fact that they start around this age (Freedman et al. 2012). As stated by this article,

“Young adulthood represents a critical time in the transition from adolescence to

adulthood, when changes in risk-taking behaviors such as experimenting with smoking

become apparent.” Males in this population are greater than females which are in relation

to other study findings. Gender in this study comprises of the community perception

regarding gender smokers and acceptance, in female smokers, stereotyping is mostly

common compared to male smoker who the community give the most acceptance. Smoking

in female as it is compared to male smokers smoke for the possible reason of style, and

occasionally compare to men who already associating the practice as a habit, and could be

seen smoking in the public without stereotyping from other people like it is seen in the

female smokers. A study done in Bangladeshi and Pakistani adults, it was noted that men

smoke more than women for a number of reasons. It was found that men smoke more



because it is socially acceptable. According to Bush et al., if women smoking it is a shamed

upon society, so if women do smoke in these cultures they usually do it in secret. Possibly

it could be seen that some women still believe it to be shameful so they may not be smoking

regularly as men do.

Middle class people are the most common group of people in society, this group of

people are commonly found in every works of life and places, and are the most sociable.

Middle class is a state of financial being where the individual is not poor nor wealthy, and

this type of people have little or nothing to worry about like the poor who probably might

be thinking of what to eat after they get up in the morning, and the rich who are more

conscious with their security and social slandered in the society. Middle class individual as

we understand from the study has no problem buying a stick of cigarette nor trying to

maintain a social standard and isolating themselves from community perception. Middle

class is the majority of the respondents gathered. According to Katainen, the working class,

also known as the middle class, is increasing in the smoking population. They had found

that it is becoming a cultural practice and work habit among blue collar workers. Results

indicate that the middle class is increasing in smoking numbers, but are also still greater to

quit as compared to the high class smokers (Barbeau et al. 2004). As stated by Barbeau et

al., smoking can provide a means of coping with frustration,” which is an understanding

statement to possible findings of our frequency findings. Smoking could be a coping

method for some student who find college work as a stressor. As for religion differences

we resulted to almost half being catholic. Reason for this is because Philippines is a

predominantly catholic denomination of Christian country, and will be a bias statement if

we say that the possibility of smoking is more among the catholic denomination. Religion

frequencies has a great deal with location in many researches.

5.2 Table 2

The average nicotine dependency score among all the participants is a low to

moderate. “Nicotine dependence is a substance abuse disorder involving compulsive drug

use in spite of known health risks” (Mendelsohn 2011). The population had an overall low



score because they are students and probably only smoke because of the stress from school.

Another reason why they are not highly addicted is because the population sample are

enrolled in health related courses where they learn the effects of cigarette smoking. Though

they are not highly dependent but they are still dependent. Table 2 shows that the mean

average of our respondents score is almost 7, they plan to quit in the next 30 days.

“Everyone has their own reasons for quitting smoking but not everyone has made plan to

quit. Factors increasing the participants’ readiness to quit smoking could be further

understood in future studies.

Mobility, self-care, usual activities, pain/discomfort, and anxiety/depression are all

different dimensions in the health related quality of life. These mean scores are low due to

the fact that nicotine dependency is also low. It was similar in Lima et al (2014) study

where it was also found a relationship between nicotine dependence and health related

quality of life.

5.3 Table 3

Demographic profile on nicotine dependency shows significance in gender (table

3). Among the sexes, females happen to have a higher nicotine dependency than men in

this research. Possible reason why is because women feel more and handle there stresses

differently than men, but we could not really ascertain the main reason why they are more

dependent to men. Women smoking are also becoming acceptable in society according to

Waldron (2002). After the nineteen twenties equality among the sexes includes smoking

unintentionally. However, the increase in female smokers in the study is because women

as men have equal right and responsibility in the Philippines and as such society does not

totally shun the habit of female smokers to cigarette, their acceptance could be another

reason of the increase in cigarette consumption and together with other factors that may

lead to them been more dependent than men as seen in the study.



5.4 Table 4

Table 4 shows that among the demographic differences age, gender, socio-

economic status, and educational attainment have no difference with the readiness to quit

smoking. This means that these are not statistically significant to the research. However,

religion has a difference to readiness to quit with a result of F=2.083 and a p-value of 0.046.

Religion is an important factor in some people. In some religions it is frowned upon to

smoke because it is disrespectful, in others it is considered a sin to harm and damage your

own body. Religion could be the motivation to quit smoking. It was found in this study that

the respondents that are Hindu are more ready to quit with Roman Catholics and other

Christian denomination with similar perceptions of their readiness. Other studies (Bash et

al., 2003; Koenig et al., 1998) have similar findings. Smoking is religiously unacceptable

(Bash et al., 2003) and that religions activities influence individuals to quit smoking

(Koenig et al., 1998).

5.5 Table 5

Our research indicates that under health related quality of life mobility, self-care,

and pain/discomfort have a weak inverse relationship to nicotine dependency. In other

words, among the participants that have a low dependency to nicotine they have a better

perception of health and vice versa. The results conclude that there is an increase in

difficulty with mobility which may be due to the fact that there is lack of oxygen to the

body. There is also the possibility that the reason the participants feel a difficulty in

mobility is because cigarettes give a relaxed feeling to some and making it difficult to

actively walk about. To conclude, the more one smokes the more he may have a relaxed

feeling. The results in the ‘Tobacco Use among Adults with Disabilities in Massachusetts’

research concludes that adults with disabilities were more likely to have ever smoked and

to be current smokers (Brawarsky et al). Smoking may be continued in these participants

possibly because a decrease in mobility influences smoking. With self-care, there was also

a decrease which also may be due to the relaxed feeling. Another probability is that when

one smokes there becomes a buildup of plaque along the teeth as seen by many dentist.



This makes it difficult to keep the oral cavity always clean. Therefore when one smokes

more, one should also clean more and take more care of his hygiene. There was not enough

supporting evidence to how smokers with high nicotine dependency have a relationship to

self-care. Pain/discomfort maybe seen in smokers that have high nicotine dependency

because the more one smokes the less oxygen they are supplying to their bodies. Cigarettes

have many substances in just one stick, after lighting it and inhaling it, it causes suffocation

to the lungs. Those smokers that are not smoking as often possibly have better lungs that

can adjust to the lack of oxygen unlike those who are highly dependent. Lack of oxygen

can cause chest pains at first because that is the first system that is affected in the body, but

later lack of oxygen will start affecting different cells within the body. In other studies

frequent headaches or frequent tiredness and stress were reported in current smokers. “Also

some people might have taken up or resumed smoking because of pain” (Palmer et al.

2003).

5.6 Table 6

Table 6 express that participant’s level of pain/discomfort and anxiety/depression

are decreased and shows that there is an increase in their readiness to quit smoking.

Participants may be using this as a motivation to quit smoking because smoking may also

be the cause of pain. Smoking, especially deep inhaled smoke causes pain in the chest

because of the many substance in smoke and the lack of oxygen which leads to cell

proliferation. Since the participants are students in the Allied Health Program, anxiety and

depression may occur in the college life because of the possibility of developing lung

cancer. Depression may be used as a motivation to quit because smoking is frowned upon

especially to these types of students. As future doctors, dentist, nurses and others of the

health team, they learn the predisposing factors of many harmful diseases which smoking

happens to be one of the main cause. Possibly feelings shamed on from being a bad

example to others who is supposed to promote a healthy lifestyle. Similarly seen in a study

from Brawarsky et al, where it was found that the adults with disabilities that are smokers

feel more pain than the adults with disabilities that don’t smoke. It was also concluded in

this study that the more pain they felt the more likely to be planning to quit smoking. Also



the participants that felt more depressed were ready to quit as similar to a study that also

found that higher depressed smokers had a greater motivation to quit smoking among

females (Haukkala et al 2000).

6.0 Conclusion

The study aims to identify the differences in demographic profiles to nicotine

dependency and to readiness to quit. Also its target is to find the impact of nicotine

dependency and readiness to quit on the health related quality of life. It involved 262

purposively selected students from a Higher Educational Institution in the National Capital

Region in Philippines. The results pose that there are significant differences with

demographic profile and nicotine dependency, namely gender and educational attainment

differences. The test used indicate that female are more dependent to nicotine compared to

male who show less dependent to nicotine. Religion was another difference between

demographic profile and readiness to quit and which the Hindus shows more readiness

compare to other religion. As for the impact of nicotine dependence on health related

quality of life, there was a significant inverse relationship with mobility, self-care, and

pain, meaning that the more one is dependent to nicotine he or she may feel more

discomfort, and less discomfort if he or she is less dependent to nicotine. Lastly, it was

seen that in readiness to quit there was also an inverse relationship on health related quality

life with pain and anxiety meaning that does with decreased anxiety/depression show more

readiness to quit smoking and decrease level of pain/discomfort, and most of the

correspondent who feel anxious/depressed smoke more and show less readiness to quit and

also feel pain/discomfort sometimes when they smoke. Therefore, the more

anxious/depressed they are the more they smoke and sometime they feel pan/discomfort

after. These results highlight that nicotine dependency and readiness to quit both have an

impact on one’s health and should be considered in further research.



7.0 Recommendation

The researchers were able to answer the questions and accomplish their

goals with this study, however, future studies could further improve this by focusing on the

results from this research. In our research we found that pain and anxiety are inversely

related to readiness to quit, future studies can discover reasons why smokers are motivated

to quit. We will also recommend that other researchers to focus on the barriers to quit

smoking among the different levels of nicotine dependence. Similar studies should be

conducted correlating to antecedents and consequences of nicotine dependence and

readiness to quit with other variables in terms of environmental factors, peer pressure,

organization affiliation, family orientation and health perception.



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Appendix A Ethics Approval



Appendix B

Permission to Use Questionnaire



Appendix C

Consent Form

Dear Sir/Ma’am,

Greetings.

The name of the research is Antecedents and Consequences of Nicotine

Dependence and Readiness to Quit among Student Smokers of Allied Health Programs in

the Philippines. This research study is envisioned to identify the relationship of

demographic profile to nicotine dependency and readiness to quit, also to identify the

relationship of nicotine dependency and readiness to quit to health related quality of life.

The research will be given in a survey question that will take no longer than 10 minutes

to answer. There are no benefits or losses that will come to the participants. The

researchers will protect the confidentiality of the participant’s data, which includes name,

age, and other information about smoking. If the participant does not wish to answer the

research questions even after saying they would participate, there will be no penalty to

the participant.

Very truly yours,

Jade P. Mojica

(Principle Investigator)

“I have read the foregoing information, or it has been read to me. I have had the

opportunity to ask questions about it and any questions I have asked have been answered

to my satisfaction. I consent voluntarily to participate as a subject in this study and

understand that I have the right to withdraw from the study at any time without in any

way it affecting my further medical care.”

Signature over Printed name

(Participant)



Appendix D Questionnaire of Demographic

Demographic Profile

1. Age:

□ 19yrs 21yrs □ 22yrs24yrs □ 25yrs 27yrs □ 28yrs 30yrs □ 31yrs or older

2. Sex (Gender):

□Male □Female

3. Religion:

□ Roman Catholic □ Christian □ Iglesia ni Cristo □ Muslim

□ Others_________________

4. Socio Economic Status:

5. Educational Attainment:

Currently Smoking

1. About how long have you been smoking?

_______Year(s) ______Month(s) ______Days

2. How many cigarettes do you usually smoke per day? (1 pack = 20 cigarettes).

_____Cigarettes

3. How soon after you wake up do you smoke?

□ Within 30 minutes □ After 30 minutes

Quitting Smoking

1. Do you want to quit smoking?

□ Yes □ No □ Unsure

2. How many times have you tried to quit smoking in the past?

_____ Times

3. What is the longest time that you have gone without smoking?

_____Year(s) _____Month(s) _____Day(s)

4. What is the ONE MOST IMPORTANT reason you want to quit smoking? (Check

ONE)

□ Health □Money □Significant others

□Social Acceptability □Religion

□Others (please describe) ________________________________________ Have Already Quit

1. Are you tempted to start again after you have quit?

□Yes □No 2. How long has it been since you stopped smoking?

_____ Year(s) _____Month(s) _____Days



Appendix E

NIDA Clinical Trials Network

Fagerstrom Test for Nicotine Dependence (FND)

Do you currently smoke cigarettes?

No Yes

If “yes,” read each question below. For each question, enter the answer

choice which best describes your response.

1. How soon after you wake up do you smoke your first cigarette?

Within 5 minutes

6 to 30 minutes

31 to 60 minutes After 60 minutes

2. Do you find it difficult to refrain from smoking in places where it is

forbidden (e.g., in church, at the library, in the cinema)?

No Yes

3. Which cigarette would you hate most to give up?

The first one in the morning Any other

4. How many cigarettes per day do

you smoke?

10 or less

11 to 20

21 to 30 31 or more

5. Do you smoke more frequently during the first hours after waking than during

the rest of the day?

No Yes

6. Do you smoke when you are so ill that you are in bed most of the day?

No Yes

Comments: Heatherton TF, Kozlowski LT Frecker RC (1991). The Fagerström Test for Nicotine Dependence: A revision of the Fagerström Tolerance Questionnaire. British Journal of Addiction 86:1119-27.


OUR LADY OF FATIMA COLEGE OF NURSING

10

9

8

7

6

5

4

3

2

1

Appendix F

Assessment of Motivation: Readiness to Quit Ladder Instructions: Below are some thoughts that smokers have about quitting. On the

ladder, circle the one number that shows what you think about quitting. Please

read each sentence carefully before deciding.

I have quit smoking.

I have quit smoking, but I still worry about slipping back, so I need to

keep working on living smoke free.

I still smoke, but I have begun to change, like cutting back on

the number of cigarettes I smoke. I am ready to set a quit date.

I definitely plan to quit smoking in the next 30 days.

I definitely plan to quit smoking in the next 6 months.

I often think about quitting smoking, but I have no plans to quit.

I sometimes think about quitting smoking, but I have no plans to quit.

I rarely think about quitting smoking, and I have no plans to quit.

I never think about quitting smoking, and I have no plans to quit.

I have decided not to quit smoking for my lifetime. I have no interest in quitting.


OUR LADY OF FATIMA COLEGE OF NURSING

Appendix G

EQ-5D-5L

Figure 1: EQ-5D-5L (UK English sample version) Under each heading, please tick the ONE box that best describes your health

TODAY

MOBILITY

I have no problems in walking about

I have slight problems in walking about

I have moderate problems in walking about

I have severe problems in walking about

I am unable to walk about

SELF CARE

I have no problems washing or dressing myself

I have slight problems washing or dressing myself

I have moderate problems washing or dressing myself

I have severe problems washing or dressing myself

I am unable to wash or dress myself

USUAL ACTIVITIES (e.g. work, study, housework, family or

leisure activities)

I have no problems doing my usual activities

I have slight problems doing my usual activities

I have moderate problems doing my usual activities

I have severe problems doing my usual activities

I am unable to do my usual activities

PAIN / DISCOMFORT

I have no pain or discomfort

I have slight pain or discomfort

have moderate pain or discomfort

I have severe pain or discomfort

I have extreme pain or discomfort

ANXIETY / DEPRESSION

I am not anxious or depressed

I am slightly anxious or depressed

I am moderately anxious or depressed

I am severely anxious or depressed

I am extremely anxious or depressed



We would like to know how good or bad your health is TODAY.

This scale is numbered from 0 to 100.

100 means the best health you can imagine.

0 means the worst health you can imagine.

Mark an X on the scale to indicate how your health is TODAY.

Now, please write the number you marked on the scale in the box below.

YOUR HEALTH TODAY =



Appendix H

Statistics Certificate



Appendix I

Budget

PRICE QUANTITY TOTAL

INSTRUMENTS

PRINTING 0.50 2,100 1,050

ENVELOPE 28.50 3 71.50

STATISTIC

REQUIREMENTS

PRINTING 79 1 79

MANUSCRIPT

OLFU COMPASS

BOOK

260 1 260

FINAL DEFENSE

PROPOSAL FEE 200 5 1,000

FINAL DEFENSE

FEE

500 5 2,500

TOTAL 1,068 2,115 4,960.5



Appendix J

TimeLine

0

2

4

6

8

10

12

14

Timeline

Number of Months (Duration) Month Sarted

Month

Started

Number of Months

(Duration)

Concept Planning 0 2

Literature Review 1.5 9

Research Planning 4 1

Proposal Defense 5.5 0.25

Ethical Review 9 0.75

Participant Selection 9.5 1

Data Collection (all) 10 1

Data Analysis 11 0.25

Final Manuscript Writing 11 1

Final Defense 12 0.25



Appendix K

About the Researchers

Jade Pohaku Maikai Mojica, the principal investigator of the study.

She is a hard working student who is kind and willing to help anyone

in need. She graduated high school in California where she was

enrolled in the Biomedical Careers Academy program where she was

CPR and first aid certified. She volunteered in school and sporting

events such as blood drives, fundraisers, and trash pickup. She started

her first year in college at Lyceum of the Philippines University and

later transferred to Our Lady of Fatima University. Her fourth year she

became emergency first aid certified, BLS- adult CPR for lay rescuers

certificate and became a member of the PRC. She plans to finish her

course in nursing and prepare herself for the licensure exam.

John Gerald A. Calisay, a co-investigator in the study. He is a kind

person who is friendly to all. He is a good listener and a student who

actively participates in class discussions. He sometimes plays

basketball, which reflects his team effort. His goals in life is to finish

his education to gain as much knowledge and skills to be an active

helper to the needs in his home place Samar.

Jason M. Franco, a coinvestigator in the study, is a former member and

officer of the Nightingale Civic Action Group. He is also a member of

Church of Christ (Iglesias Ni Cristo), and a former choir member. As a

member he helped in community clean up drives, and participated in

blood donations. In high school in New York, he was a member of the

photography club and cross country he also learned CPR in his health

class.



Vikhuli Hansen, a coinvestigator of the study. She was one of the

International Students Organization Executive officers in the previous

college. She was a social worker in India and sent by her church leaders to

china and Thailand for Christian work. She was a nursing assistant in an

old care center in America and got best care giver appreciation award. After

graduating from Fatima, she plans to go back to America where she will

achieve her goal of opening a care center for the elderly so she may help

the poor and needy.

Owoh Joshua Amobi, a co-investigator in the study and the

presenter of the research paper. He is known with a character of

goal oriented and a strong will of achieving success in any event

of life even when the path to obtaining it is stiff, and as such drove

him toward obtaining the award of the best performing foreign

student in his former school, Lyceum of the Philippines University

Batangas. After his transfer to Our Lady of Fatima University, he

also obtained the certificate of the best case presenter in all third

year level interclass case presentation he is also a member of the

RED CROSS Valenzuela City Chapter Philippines. He obtains a

certificate in Disaster Nursing, and a Certified Emergency First

Aide Personnel, and a certified Basic Life Support-Adult CPR for Lay Rescuer PRC-Valenzuela

City Chapter. Joshua is a Senior Consultant with Edibongus Global LMT. He is a kind of student

who finds education as the key toward confidence of self-expression, and acquiring vast

knowledge. And God willing, he hope to further his education to becoming a medical doctor in the

nearest future, hence, giving back to the community the sense of vision if.



Acknowledgment

We would like to express our special thanks of gratitude to our advisers, Sir Clarence and

Jenica A. Rivero, who gave us the knowledge and guidance to conduct and put together this

study. We are now ready for future studies of our own from the understanding you had given us.

Secondly, we would like to thank the Research Development and Innovation Center for

helping, improving our study. We would like to give a special thank you to Dianna Eraphie A.

Tao-on and Michael Joseph Dino for statistical results and for enhancing our understanding of

research.

Thirdly, we would like to thank the students of the Allied Health Programs enrolled in

Our Lady of Fatima University for participating in our research because without you we would

not have an understanding to our study.

Lastly, we would like to thank our family and friends for being supportive during our

research by reminding us to focus on our goal and achievement.

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