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University of Southern California Dissertations and Theses

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The effect of an educational fotonovela on the prevention of secondhand smoke

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The effect of an educational fotonovela on the prevention of secondhand smoke

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THE EFFECT OF AN EDUCATIONAL FOTONOVELA ON
THE PREVENTION OF SECONDHAND SMOKE

By

Angélica Delgado Rendón

A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF PHILOSOPHY
(PREVENTIVE MEDICINE/HEALTH BEHAVIOR RESEARCH)

December 2019

ii
APPROVAL OF THE REVIEW COMMITTEE
This dissertation has been duly read, reviewed, and critiqued by the Committee listed
below, which hereby approves the manuscript of Tatiana as fulfilling the scope and quality
requirements for meriting the degree of Doctor of Philosophy in Health Behavior.

Jennifer Unger-Hamilton
University of Southern California
Committee Chair

Tess Boley Cruz
University of Southern California
Committee Member

Lourdes Baezconde-Garbanati
University of Southern California
Committee Member

Steven Lopez
University of Southern California
External Committee Member

iii
Table of Contents
List of Figures………………………………………………………………………………….iv
List of Tables……………………………………………………………………………….….iv
Abbreviations and Acknowledgements………………………………………………………...v
Abstract ………………………………………………………………………………………..vi

Chapter 1: Background, Context, and Significance………………………………………….…1
Exposure to Secondhand Smoke in Multi-Unit Housing………………………….……1
Health Literacy…………………………………………………………………….……3
Graphic Novels…………………………………………………………………….……5
Theoretical Background………………………………………………………………...7
Summary of Studies……………………………………………………………………10
Aims and Hypotheses…………………………………………………………………..11

Chapter 2: Mediation Analysis of a Bilingual Educational Intervention Guided by Social Cognitive
Theory for the Prevention of Exposure to Secondhand Smoke………………………………...15

Introduction……………………………………………………………………………..15
Methods………………………………………………………………………………....28
Results…………………………………………………………………………………..33
Discussion…………………………………………………………………………….…41
Limitations………………………………………………………………………………44
Conclusions……………………………………………………………………………..45

Chapter 3: The Role of Health Literacy in a Bilingual Educational Intervention for the Prevention of
Secondhand Smoke among Hispanics ………………………………………………….……….47

Introduction……………………………………………………….……………………..47
Methods……………………………………………………………….…………………53
Results………………………………………………………………….………………..60
Discussion……………………………………………………………….………………68
Limitations………………………………………………………………………………71
Conclusions……………………………………………………………………………...71

Chapter 4: Conclusion……………………………………………………………………………73

Summary of Findings…………………………………………………………………….73
Theoretical Implications……………………………………………………….…………75
Methodological Implications…………………………………………………….……….75
Implications for Future Research…………………………………………….…………..76
Implications for Practice Settings………………………………………………………..77
References…………………………………………………………………………….………….79
Appendix A: Survey Instruments………………….……………………………………………..90

iv
List of Figures

Figure 1: Cover of the fotonovela Rosa Out of Control. ................................................................. 7
Figure 2: Conceptual framework for study 1 ................................................................................ 10
Figure 3: Conceptual framework for study 2 ................................................................................ 11
Figure 4: Conceptual framework for study 2 ................................................................................ 13
Figure 5: Conceptual framework for study 2 hypothesis 2. .......................................................... 14
Figure 6: Sample pages of El Reto de Marta (Marta in a Mission). .............................................. 25
Figure 7: Study mediation model………………………………………………………………...27
Figure 8. Conceptual framework for study 1 ................................................................................. 28
Figure 9: Mediation path of self-efficacy ...................................................................................... 39
Figure 10: Final model based on mediation paths ......................................................................... 41
Figure 11: Scene from the fotonovela Marta on a Mission ........................................................... 54
Figure 12: Conceptual framework for study 2. ............................................................................. 59
Figure 13: Conceptual framework for study 2 hypothesis 2 ......................................................... 60

List of Tables

Table 1: Timeline of data collection and study measures. ............................................................ 26
Table 2: Participant characteristics per treatment condition ......................................................... 34
Table 3: Psychosocial scales by treatment condition .................................................................... 34
Table 4: Intercorrelations among study variables ......................................................................... 35
Table 5: Cross-sectional associations of key outcomes. ............................................................... 37
Table 6: Association of changes in self-efficacy by intervention type .......................................... 39
Table 7: Demographic characteristics of the sample population by treatment condition ............. 62
Table 8: Participant characteristics by level of Spanish health literacy ........................................ 65
Table 9: Participant characteristics by level of English health literacy. ........................................ 66
Table 10: Intercorrelations among study variables and health literacy items ............................... 67

v
List of Abbreviations

FHS – Firsthand Smoke SHS – Secondhand Smoke
MUH – Multi-Unit Housing SHMS– Secondhand Marijuana Smoke
SCT – Social Cognitive Theory THS – Thirdhand Smoke
Acknowledgements
I wish to thank my very supportive family, my parents Blanca Esthela Rendón Rivas and Arturo
Delgado Muñoz, my aunt, Ana Rendón Rivas, my uncle, Samuel Rendón Rivas, and all my
familia for their love, humor, company, patience, and ideas. Much gratitude to my mentor Dr.
Tess Boley Cruz, her time and dedication to students’ learning have not gone unnoticed; her
critical thoughts, engagement, and support were key to getting through the difficult periods of
my doctoral studies and finishing my dissertation and I will be eternally grateful to having her as
a mentor. I hope to follow her example to guide my students. I thank my wonderful committee
chair Dr. Jennifer Unger-Hamilton for her wisdom and patience, Dr. Lourdes Baezconde-
Garbanati for encouragement, and Dr. Steven Lopez for his insights. I am forever thankful to my
program godmothers Marny Barovich and Sherri Fagan, whose sense of humor, generosity, and
encouragement lessened the burden and helped me see the light at the end of the tunnel. Thanks
to Sheila Yu, for her time and friendship, Kellie Imm for her support, Tatiana Basañes for being
a role model and for inspiring me, Cheng Wen (Freddy) for his talent teaching me statistics, and
Robert Garcia for his support and guidance during the rough times. To the USC Eric Cohen
Student Health Center staff for helping me at crucial moments along the way, especially Dr. Lina
Augius and Dr. Kimberly Tilley; who cared for my physical and mental wellbeing. From my
days at the Centro de la Comunidad Unida to my colleagues whose critical thoughts contributed
to my professional development; our partners from the Medical College of Wisconsin,
University of Wisconsin, and Marquette University.
vi
Abstract
The study design was a three-group prospective randomized controlled trial comparing
the effectiveness of a graphic novel (fotonovela), a text heavy pamphlet, and no material in
changing Hispanic residents’ attitudes and behaviors towards exposure to secondhand smoke
(SHS). The purpose of the first study was to evaluate the direct and mediation effects of social
cognitive theory constructs in an educational intervention for the prevention of secondhand
smoke among Hispanic apartment residents in Los Angeles County. Participants were randomly
assigned to either exposure to a fotonovela, a pamphlet, or no educational material (n = 337).
Mediation analysis was performed to assess the contribution of specific Social Cognitive Theory
constructs on the efficacy of an educational fotonovela. Protective behaviors related to SHS at
follow up were better for the brochure and fotonovela intervention groups than for the control.
For the fotonovela group participants, baseline perceived self-efficacy (T1) and collective
efficacy at follow up (T2) were associated with protective attitudes about talking with neighbors.
Social cohesion and communication with neighbors correlated strongly with self-efficacy,
collective efficacy, and protective behaviors. Mediation analysis of the social cognitive theory
constructs revealed potential psychosocial paths from self-efficacy at baseline to protective
behaviors against exposure to SHS at follow up via collective efficacy. A potential model of the
causal structure from self-efficacy to protective behaviors of SHS is proposed. Neighborhood
characteristics of social cohesion and frequency of communication with neighbors and manager
are important factors when designing interventions to decrease SHS pollution in shared and open
spaces.

vii
The second analysis examined the direct and moderating effects of health literacy in
educating Hispanic residents about risks and protective behaviors related to SHS. Residents in
randomly selected Hispanic apartment buildings in Los Angeles County (n = 337 participants)
completed a pretest survey and were then randomly assigned to receive either a fotonovela,
pamphlet, or no material on secondhand smoke. Moderation analyses were conducted to evaluate
the interaction effects of English and Spanish health literacy levels on the association between
study group assignment and knowledge, attitudes, collective efficacy, and protective behaviors.
Individuals with high Spanish health literacy (SHL) were more likely to favor all types of
smoking bans and report higher collective efficacy to protect themselves and their families at
follow up. Moderation analysis did not reveal any interaction effects between the type of
educational materials exposure and SHL or English health literacy (EHL) on knowledge,
attitudes, and behavior. Stratifying by preferred language, moderation analysis showed that for
Spanish speakers only SHL interacted with the association between reading the pamphlet and
knowledge about SHS. The health literacy study only found interaction effects of Spanish health
literacy on the association between type of material (pamphlet) and knowledge for Spanish
speakers. Participants with high SHL reported higher collective efficacy to deal with SHS
exposure. Further research is needed to clarify the immediate effects of health literacy for
Hispanics with low health literacy in either language.

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Chapter 1. Introduction
Exposure to Secondhand Smoke in Multi-Unit Housing
Secondhand Smoke (SHS) is the smoke that is exhaled by a smoker and subsequently
inhaled by non-smokers nearby (U.S. Department of Health and Human Services, 2006)
Secondhand Marijuana Smoke (SHMS) is the smoke from a burning joint that is inhaled by
others (Holitzki, Dowsett, Spackman, Noseworthy, & Clement, 2017). Thirdhand smoke (THS)
is composed of the chemicals from SHS that settle on surfaces such as furniture, clothes, and
upholstery that continue to pollute the environment long after the smoker has left the area
(Luciana Rizzieri, Ana Luiza, & Denise Conceição Mesquita, 2016). Exposure to SHS, SHMS,
and THS in multi-unit housing is a threat to Hispanics’ health. Hispanics make up 18.3% of the
population of the United States and are expected to become one third by the year 2050 (Bureau,
2019; Passel & Cohn, 2008). In Los Angeles County, Hispanics are the largest ethnic group
accounting for 48.5% of the population (Bureau, 2017). Hispanics of any race are less likely to
be homeowners and more likely to rent apartments than European Americans (Hispanics 54%
and European Americans 28%) (Cilluffo, Geiger, & Fry, 2017; Salviati, 2017). Given the
economic trends since the 2008 housing market crash, the number of people living in multi-unit
housing is expected to increase (Cilluffo et al., 2017). Living in close proximity to large number
of neighbors place Hispanics at higher risk of exposure to secondhand smoke than other ethnic
groups (Baezconde-Garbanati et al., 2011). Even though Hispanics have high rates of smoking
bans at home, smoke can infiltrate from neighboring units, passersby smoking in the sidewalk,
through ventilation systems, and from common open areas in the property (Delgado-Rendon,
Cruz, Soto, Baezconde-Garbanati, & Unger, 2017). In 2016, the federal government issued a
smoking ban in all public housing units (U.S. Department of Housing Authorities, 2016)

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However, the policy does not apply to private housing properties and SHS can continue to
pollute apartment units from outside sources (Delgado Rendon, Cruz, Baezconde - Garbanati,
Soto, & Unger, 2019).
The devastating effects of firsthand and secondhand smoke are well known to lay people:
lung cancer, respiratory illnesses, cardiovascular disease, and poor birth outcomes, among many
other adverse outcomes (U.S. Department of Health and Human Services, 2014). The public
health agenda has expanded to include electronic cigarettes, hookah, and marijuana as new
sources of air pollution (Barry, Heikki Hilamo, & Glantz, 2014; Protano, Manigrasso, Avino, &
Vitali, 2017; Waziry, Jawad, Ballout, Al Akel, & Akl, 2017). Recent studies have revealed that
the vapor from electronic cigarettes (vaping) also contains carcinogens and nicotine, an addictive
substance, among other harmful chemicals (Goniewicz et al., 2014, Quintana et al., 2019). The
Center for Disease Control and Prevention has released a warning to stop smoking e-cigarettes
after an outbreak of lipoid pneumonia was linked with vaping (Kevin Davidson et al., 2019; Viswam,
Trotter, Burge, & Walters, 2018).
As of May 2019, marijuana consumption for medicinal purposes was legal in 33 states
and Washington D.C., and for recreational purposes it was legal in 11 states and Washington
D.C (Procon.org, 2019). Secondhand marijuana smoke poses respiratory problems and
psychoactive effects to people who breath it (Holitzki et al., 2017; Posis et al., 2019). Several
states are making strides to include the use of electronic cigarettes in laws regulating smoke free
venues, however policies regulating the use of marijuana in public and shared spaces are still in
the beginning stage (American Non-Smokers’ Rights Foundation, 2019). Alternative nicotine
delivery systems (electronic cigarettes) are used to consume marijuana products and this practice
has been associated with harmful outcomes (He, Oks, Esposito, Steinberg, & Makaryus, 2017).

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While the government and organizations work to create and enforce smoking bans in
Multi-Unit Housing (MUH), it is important that health professionals educate Hispanic residents
on the risks of exposure to SHS. Awareness of a health issue would enable Hispanics to take
action in their family’s best interest. Numerous printed health education materials exist, but
many are not accessible or acceptable to audiences with low health literacy and few have been
evaluated rigorously before being disseminated (Wilson et al., 2012). The purpose of this
dissertation was to assess the relationship between processes of social learning and the effect of
an educational fotonovela on the prevention of exposure to SHS.
Health Literacy
One of the goals of Healthy People 2020 is to use health communication strategies to
improve population health outcomes and health care quality, and to achieve health equity (U.S.
Department of Health and Human Services, 2019). The first objective listed under this primary
goal is to improve the health literacy of the population. Health literacy is “the degree to which
people have the capacity to obtain, process, and understand health information to make
appropriate health decisions” (Kutner, 2006; Ratzan, 2001).
Low formal education has been considered a determinant in health outcomes for many
years. Several studies have linked low levels of health literacy as a mediator of poor health
outcomes (Mengyun et al., 2018; Stormacq, Van Den Broucke, & Wosinski, 2018). Among
English-speaking seniors, inadequate health literacy is linked to medication non-compliance
(Nidia Farias Fernandes et al., 2017). A previous investigation showed that for HIV patients
reading comprehension mediated the relationship between race (Black/African American,
White/EA, other) and management of their retroviral medication (Waldrop-Valverde, Raphiel
Jamale Murden, Ying Guo, Marcia Holstad, & Raymond L. Ownby, 2018).

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For Hispanics residing in the United States, the association between health literacy and
quality of life is compounded by disparities in health insurance, access to health care, quality of
schools, and language speaking discrepancy with health care providers (Sarkar, Asti, Nacion, &
Chisolm, 2016). Spanish was the official language in many parts of the territory that would
eventually be invaded and dominated by Anglo Europeans (Lozano, 2019). The use of Spanish
as an official language was gradually taken over by the growing number of Anglo Europeans
arriving in stolen Mexican territory after the U.S. – Mexico war of 1848. In Puerto Rico, a
territory considered part of the Commonwealth of the U.S., Spanish continues to be language of
use in spite efforts made by the U.S. to anglicize the island (Lozano, 2019). Today, use of Native
American and Spanish languages is equated as foreign, even though they preceded the English.
As Lozano points out “English has always been the dominant language of the nation, but the
United States has never been an English-only society. The long multilingual experience of the
United States has remained largely absent from popular understandings of the nation’s history”
(Lozano, 2019). Furthermore, the U.S. does not have an official language. Although Spanish has
endured in several states and is currently the 2
nd
most spoken language in the United States, it is
not treated equally to English. Research on Hispanics’ health literacy has focused on the English
language, even though only 25% are English dominant, 36% are bilingual, and 38% are Spanish
dominant (Koskan, Friedman, & Hilfinger Messias, 2010; Krogstad & Gonzales-Barrera, 2015).
The United Nations Educational, Scientific, and Cultural Organization (UNESCO) recognizes
minorities’ equality of language use with the dominant language as a human right, even more
when these groups preceded the imposition of another language by force (De Varennes, 2001).
There are several health literacy tests that have been validated in English and Spanish,
however, these are time consuming and can be intimidating to people with low literacy (Aguirre,

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Ebrahim, & Shea, 2005; Dumenci, Matsuyama, Kuhn, Perera, & Siminoff, 2013; Monsalves,
Mañalich, & Fuentes, 2016). Sarkar and colleagues evaluated the validity of three single item
screener questions with Hispanics and one of the items, “How confident are you filling out
medical forms?” accurately identified people with inadequate health literacy (Chew, Bradley, &
Boyko, 2004; Sarkar, Schillinger, Lopez, & Sudore, 2011). Dr. Hadden and her team further
clarified the language of health literacy (English and/or Spanish), discovering that “confidence in
filling out forms in English” can distinguish better than other measures among Spanish speakers
with inadequate and adequate health literacy (Hadden, Prince, Rojo, Selig, & McElfish, 2019).
This dissertation aimed to evaluate the role of health literacy in the effects of a bilingual
educational intervention to inform Hispanic apartment residents how to address SHS. The
intervention consisted of two educational materials, a fotonovela, El Reto de Marta/Marta on a
Mission, a text pamphlet, and a control group that did not receive an educational material.
Graphic Novels
The field of cognitive psychology defines the narrative or experiential method of
communication as a way in which humans process information using entertaining stories,
historical accounts, experiences of oneself and of others, and events in sequential order from
beginning to end (Bruner, 1986; Hinyard & Kreuter, 2007). People use affect heuristics, such as
pictures that remind them of previous experiences, to make quick assessments about risks more
commonly than they use analytical processes (Slovic, Finucane, Peters, & Macgregor, 2004).
Communication methods to aid people with low health literacy using the narrative/experiential
system include graphic narratives. A narrative is a story, written, verbal, or visual (with graphics
or pictures) which connects a series of events. Using pictures and graphics can help lower the

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literacy level of the educational materials as many symbols and human expressions are universal
and easily interpreted.
Fotonovelas, comic books, comic strips, and manga are a form of small print
entertainment that use pictures, graphics, cartoons, and brief dialogue to tell stories (Toku, 2001).
Fotonovelas first originated as stills from movie scenes in Italy and evolved to become a popular
diversion in Spanish speaking countries (Butler Flora, 1980). Fotonovelas are a common style of
novel among Hispanics that contain interesting and suspenseful storylines reminiscent of the
popular telenovelas (seasonal soap operas with an ending). Fotonovelas come in comic – book
format with brief texts in dialogue bubbles generally depicting dramatic or romantic genres.
Researchers and public health professionals have used these types of print media to deliver
health messages in the hopes that the messages are easier for the target audience to interpret and
act upon than traditional health materials offered in clinics. For example, It’s never too late to
start exercising, is a fotonovela that is part of a national campaign from the NIH National
Institute on Aging to help seniors engage in physical activity and stay independent as they age an
can be downloaded from the internet (National Institutes of Health, 2010) A series of fotonovelas
focused on role-modeling healthy behaviors were created by a collaboration between faculty
from the University of Southern California’s School of Pharmacy and Department of Preventive
Medicine and have been studied among Hispanics, Koreans, and other groups (Cabassa,
Contreras, Aragon, Molina, & Baron, 2011; Unger, Molina, & Baron, 2009).One of their
fotonovelas, Rosa Out of Control tells the journey of a Mexican-American family overcoming
obesity with healthy eating habits and physical activity (See Figure 1) (Baron, Lopez, Molina,
Lopez de Dennis, Zendejas, Sharma, Powers, 2012).

7

Fotonovelas have demonstrated success in some populations.
Hispanic immigrant community members have identified a need for
medical information without jargon, poor Spanish translations,
complicated terms, and in an interesting style (Sberna Hinojosa et al.,
2010). Health experts recommend adapting communication campaigns
to Hispanics’ characteristics and cultural values (Elder, Ayala, Parra-
Medina, & Talavera, 2009). Fotonovelas have been well received by
Spanish speaking communities in across the United States addressing
a variety of topics: obesity, diabetes, exposure to secondhand smoke,
dementia, and depression (Cabassa et al., 2011; Unger et al., 2009; Unger, Soto, Rendon,
Baezconde-Garbanati, & Cruz, 2019; Valle, Yamada, & Matiella, 2006).
Theoretical Background
Health education’s role in health behavior change is crucial to raise awareness of risk
factors, harm reduction, prevention, and maintenance (Glanz, Rimer, and Marcus Lewis, 2015).
Partnerships between communication and health experts have yielded ideas about how health
education strategies increase the audience’s awareness of a health topic. The main theories that
have been proposed to explain the persuasive effects of graphic narratives for health behavior
and education are: Social Cognitive Theory (SCT), Transportation Theory (TT), Elaboration -
Likelihood Model, Entertainment – Education, and Empowerment Education (Bandura, 1998,
Freire, 2000, Green, Strange, & Brock, 2002; Johns Hopkins Bloomberg School of Public
Health, 2008; Kitchen, Kerr, E. Schultz, McColl, & Pals, 2014; Moyer-Gusé, 2008; Petty &
Cacioppo, 1983). However, gaps in the literature remain about these theories’ effectiveness in
explaining and predicting behavior change. Elaboration – Likelihood Theory posits that there are
Figure 1. Cover of the
fotonovela Rosa Out of
Control.

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two ways human use for processing information, central and peripheral, the central undertakes a
thorough examination of the information provided and the peripheral a more superficial view
before deciding to act on that information (Petty & Cacioppo, 1984). Methods for delivering the
information in an entertaining way such as the fotonovela could bypass the central way and
lower counterarguing to persuade the audience to engage in the actions portrayed in the story
(Petty & Cacioppo, 1986). Entertainment – Education expands ELT’s use of the peripheral route
of processing information to mass media formats that use storylines (Johns Hopkins Bloomberg
School of Public Health, 2008). EE attempts to appeal to the audience’s emotions and inspire
them to follow the example of the story’s characters. There is enough evidence of the
contribution of SCT and TT to persuading an audience to improve their behaviors. Paulo Freire
founded the school of critical pedagogy leading to Empowerment – Education; facilitating a
person’s learning through their own reflections (Freire, 1970). While the theories before
mentioned deserve their own merit in health research, our research team decided to use SCT and
TT to guide the design and evaluation of the fotonovela. There is more evidence of the
effectiveness of SCT and TT in persuading an audience to follow a role model’s behaviors. The
main premise of Transportation Theory is that when a reader becomes mentally transported into
storylines of excellent quality, the reader is most susceptible to persuasion by the information
and events presented in the plot (Green et al., 2002). Murphy and colleagues published findings
supporting the premise that transportation into a narrative versus a non-narrative method
influenced the audience’s shifts in knowledge, attitudes, and behavioral intentions (Murphy,
Frank, Chatterjee, & Baezconde-Garbanati, 2013). Albert Bandura observed that children tended
to emulate the actions of others, referred to as role models (Bandura, 1977), Bandura developed
SCT as a type of social learning when people develop the skills by first observing a role model

9

and then practicing the behavior until reaching proficiency, a process he referred to as self-
efficacy. When people accomplish a goal together, it is collective efficacy. Additionally, people
can learn new skills by watching role models in a video (through television or computer monitor
or projector), thus reducing barriers for teaching hard to reach groups of people. Combined, SCT
and TT predict that when healthy skills are presented in a narrative format in an entertaining
way, the audience will be persuaded to change their attitudes and behaviors to more closely
follow the characters in the story. Other SCT constructs are described in detail in chapter two.
The current state of knowledge has gaps on regards to if and how the social cognitive process
described by Bandura results in changes in behavior (Figure 2).
Involuntary smoke pollution in apartment complexes is a health risk that exists in a social
setting. It is logical to consider a social learning framework to help reduce exposure. The
proposed research aimed to examine the effects of SCT’s constructs (self-efficacy and collective
efficacy) on persuading multi-unit housing Hispanic residents to change their attitudes and
behaviors towards prevention of exposure to SHS, SMHS, and THS. The study model was
inspired by Bandura’s integrated causal model from self-efficacy to actually performing the
desired behavior (See Figure 2). The proposed research aims to examine effects of the theory’s
constructs on knowledge, protective attitudes, favoring bans, and protective behaviors to prevent
exposure to Secondhand Smoke, Secondhand Marijuana Smoke, and Third-hand Smoke among
multi-unit housing Hispanic residents in Los Angeles County. Protective attitudes include
thinking positively about engaging in conversations with neighbors and management about
addressing exposure to SHS. Protecting behaviors include actually addressing exposure to SHS
with others in the property. The dosage of number of barriers to engage in protecting behaviors
should be negatively associated with intentions to act.

10

Summary of Studies
This dissertation is a sub-study of an intervention funded by the Tobacco-Related Disease
Research Program (Unger et al., 2019). The study design was a three group pre/post-test:
fotonovela, pamphlet comparison group, and control group did not receive an educational
material. The participants were recruited from pre-selected MUH in areas of Los Angeles County
with high concentrations of Hispanics (Delgado-Rendon et al., 2017). A total of 337 residents
completed the baseline (T1) and follow up (T2) surveys (Fotonovela n = 115, pamphlet n = 108,
control group n = 114). The proposed studies are significant and innovative for two reasons: 1)
The analysis proposed will fill a gap because no other randomized controlled study has been
done with multi-unit housing dwellers testing Social Cognitive Theory; and 2) this study is
pivotal to health promotion because it will advance our understanding of the effects literacy
levels of the materials and study participants on reducing tobacco related diseases. Few to
none published studies have reported and evaluated the literacy level of graphic educational
materials and the participants; less have examined individual differences in health literacy among
bilingual participants.
Figure 2. The study model was guided by Bandura’s integrated causal structure of social
cognitive theory from self-efficacy to behavior (Bandura, 1998).

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Study 1: Mediation Analysis of a Bilingual Educational Intervention Guided by Social
Cognitive Theory for the Prevention of Exposure to Secondhand Smoke
Exploratory Aim: The correlations and associations among Social Cognitive Theory constructs
and sociodemographic characteristics of the study groups were explored.
Hypothesis 1: Self-efficacy (T1 and T2) and collective efficacy (T2) will be positively associated
with protective attitudes about SHS/THS (T2), favoring bans of SHS/THS (T2), and protective
behaviors related to SHS/THS (T2) among the participants in the fotonovela cohort at follow up.
Furthermore:
a) Self-efficacy (T1 and T2) will mediate the associations between protective attitudes (T1)
and behaviors (T2).
b) Self-efficacy (T1 and T2) will mediate the association between intentions (T1) and
behaviors (T2).

Hypothesis 2: Self-efficacy to protect self and family will be higher among the participants in the
fotonovela cohort than those of the comparison and control cohorts at follow up (Fotonovela >
Pamphlet > Control). The graphics in the fotonovela are expected to ease the understanding of
the messages when compared to the text heavy pamphlet.
Figure 3. Conceptual framework for study 1 consisting of the fotonovela group.

12

Hypothesis 3: The fotonovela will result in improvements in key outcomes about SHS/THS
(protective attitudes and behaviors) as compared to the other study groups. There will be
mediation effects of social cognitive theory constructs following Bandura’s integrated causal
structure (See Figure 2 in page 10).
a) Positive outcome expectations (T2) will mediate the relationship between self-efficacy
(T1) and intentions to behave in protective ways (T2).
b) Collective efficacy (T2) will mediate the association between intentions to engage in
protective behaviors (T2) and behaviors (T2).
c) Self-efficacy (T1) will be positively associated with protective behaviors (T2)
d) Positive outcome expectations (T2) will be positively associated with protective
behaviors (T2).
e) Negative outcome expectations (T2) will be negatively associated with intention to
engage in protective behaviors (T2).
f) Self-efficacy (T1) will be negatively associated with barriers (T1)
g) There is a dosage effect as in the number of self-reported barriers to engage in protective
behaviors (T1) will be negatively associated with intentions (T1 and T2).

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Study 2: The Role of Health Literacy in a Bilingual Educational Intervention for the
Prevention of Secondhand Smoke among Hispanics
The following statements include an exploratory aim and hypotheses of the first study.
Exploratory Aim: The correlations and associations among health literacy, outcomes, and
sociodemographic characteristics of the study groups were explored. Significant intercorrelations
will be reported to inform future research and implementation of health communication
programs.
Hypothesis 1: The outcomes of the fotonovela and pamphlet groups will be weaker for
participants with low English health literacy and Spanish health literacy than for participants
with high health literacy. Participants with higher health literacy at baseline will better
understand the messages imparted in the study since they can read better than those with lower
health literacy. Outcomes will be stronger for individuals with high English health literacy and
Spanish health literacy versus those with low health literacy. Outcomes include knowledge about
SHS/SHMS/THS, protective attitudes, favoring smoking bans, and engaging in protective
behaviors.

Hypothesis 2: The association between group placement and follow up outcomes will be
moderated by levels of EHL/SHL when stratified by primary language for both fotonovela and
Figure 4. Conceptual framework for study 2.

14

pamphlet comparison groups (Separate participants by the language they preferred for
completing the survey in English and Spanish speaking groups).
a) Among participants who prefer to speak Spanish: Health literacy in Spanish will
moderate the association between study group placement and outcomes (knowledge,
protective attitudes, favoring bans, and protective behaviors). Those participants with
higher literacy in Spanish will perform better in the outcome measures than those with
low literacy.
b) Among participants who prefer to speak English: Health literacy in English will moderate
the association between study group placement and outcomes (knowledge, protective
attitudes, favoring bans, and protective behaviors). Those participants with higher literacy
in English will perform better in the outcome measures than those with low literacy.

Figure 5. Conceptual framework for hypothesis 2 of study 2.

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Chapter 2. Mediation Analysis of a Bilingual Educational Intervention Guided by Social
Cognitive Theory for the Prevention of Exposure to Secondhand Smoke
Introduction
Exposure to Smoke in Multi-Unit Housing
Secondhand smoke from the combustion of tobacco (SHS) or marijuana products
(SHMS) continue to be contributors of indoor smoke pollution and a factor increasingly found to
be impacting health (Holitzki et al., 2017; U.S. Department of Health and Human Services,
2006). In contrast, exposure to Thirdhand Smoke (THS) is being subjected to the involuntary
touch, ingestion, or breathing of the smoke pollutants that have penetrated objects and surfaces
(Matt et al., 2011). Exposure to Secondhand Smoke (SHS) and Thirdhand Smoke (THS) from
tobacco and marijuana products in multi-unit housing (MUH) are threats to public health
(Delgado-Rendon et al., 2017; Makadia, Roper, Andrews, & Tingen, 2017). One in four non-
smokers older than 3 years of age is exposed to SHS (Homa et al., 2015). Electronic cigarettes
contain toxicants similar to other tobacco products and their chemicals have been detected in
children’s urine samples (Quintana et al., 2019). The pathological effects of SHS on people
include higher risk of cancer, asthma, inflammation, sudden infant death syndrome, and low
birthweight (Makadia et al., 2017; U.S. Department of Health and Human Services, 2006). The
long-term adverse effects of THS from tobacco remain inconclusive; however, studies show that
the SHS chemicals absorbed in the furniture and car fixtures had toxic effects on cell and animal
models that included DNA damage, hyperglycemia, respiratory problems, and carcinogenic
evidence (Díez-Izquierdo et al., 2018).
Marijuana smoking is becoming more prevalent with an estimated 5 to 8 million children
living with a parent who smoked marijuana in the month prior to the last poll (Goodwin et al.,

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2018). SHMS has recently been associated with adults’ psychoactive effects, eye irritation and
discomfort and with children’s adverse health outcomes (i.e. respiratory problems, ear infections,
and asthma) independently of tobacco SHS (Holitzki et al., 2017; Posis et al., 2019). The Center
for Disease Control and Prevention recently put out a health advisory to warn people of the
potential link between vaping (smoking electronic cigarettes) and severe lung disease (Viswam
et al., 2018). Some of the cases of severe lung disease have been linked to the addition of off the
streets Delta-9-tetrahydrocannabinol (THC), an active ingredient in cannabis, to vaping devices
(He et al., 2017).
Due to economic disparities, living with a larger number of family members in the same
household, and proximity to a larger number of neighbors, Hispanic apartment residents in urban
communities endure higher rates of exposure to SHS, SHMS, and THS than single home
residents (Baezconde-Garbanati et al., 2011; King, Babb, Tynan, & Gerzoff, 2013; Matt et al.,
2011). Hispanic residents with low socioeconomic status face more financial challenges to afford
living in clean air neighbors than Anglo-Americans (Woo et al., 2019). Aside from financial
difficulties, cultural and linguistic barriers complicate Hispanics’ interpersonal relationships with
landlords and neighbors for addressing SHS/SHMS/THS (Delgado Rendon et al., 2019).
Children, seniors, and disabled adults are captive to MUH indoor pollution as they have reduced
agency to avoid breathing it. The USC research team created a bilingual educational fotonovela
guided by Social Cognitive Theory (SCT) to educate Hispanic apartment residents on the health
risks of SHS. The purpose of this study is to assess the relationship between Hispanics’ self and
collective efficacy and the impact of the fotonovela on protective behaviors related to SHS.

17

Theoretical Background
SCT posits that humans acquire skills by observing role models performing actions and
then practicing until they feel confident enough to perform the action effectively (Bandura,
1977). The main constructs of SCT are self-efficacy, collective efficacy, observational learning,
outcome expectations, and behavioral capability (Bandura, 1995; Kelder, Hoelscher, Perry,
2015).
Self-efficacy is one of the most important and well-studied concepts in health behavior
theories. Perceived self-efficacy is a person’s confidence in their capabilities to achieve desired
outcomes (Bandura, 1994). Albert Bandura theorized that efficacy beliefs and outcome
expectations represented the conditional relations between the person and the desired outcomes
(Bandura, 1998). For Bandura, a person’s control beliefs can affect their expectations of their
own efficacy in performing the behavior needed and the expectations of the outcomes of that
behavior (Bandura, 1995). People’s actions sometimes are more catalyzed by their beliefs of
whether or not they can produce an effect than what is really possible in their circumstances
(Bandura, 1995).
Self-efficacy for a specific behavior is situationally bound, so it is related to the
conditions in which the behavior would occur. For example, a person may feel more confidence
to ban smoking at home to protect his/her children from exposure to carcinogens than if he/she
were without dependents.
As a construct, self-efficacy is operationalized differently in various research studies and
across fields. As a construct of Social Cognitive Theory, Albert Bandura theorized that self-
efficacy is affected by mastery experiences, role modeling (vicarious living), positive persuasion,
and by reducing people’s stress reactions while attempting to engage in the new or modified

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behavior (Bandura, 1995). Role modeling provides a standard by which the reader can judge
their own abilities. Furthermore, having competent role models that share similar cultural
characteristics and challenges increases the odds that the audience will adopt the behaviors.
Hispanics’ higher external locus of control may affect their self-efficacy if they perceive a lack
of perceived control over other people’s smoking habits (Sue & Sue, 2008). Efficacy beliefs
have been shown to mediate reactions to stressful situations especially after mastery experiences
(Bandura, 1998). Also, people who are less ready to change have been shown to have lower self-
efficacy in that specified skill than people who are ready to change or already engaging in the
behavior change (de Vries H & E., 1994). A person’s beliefs on their capacity to learn affect
their gradual improvements and adapt to the challenges encountered. In this case, a person may
have some degree of self-efficacy to deal with SHS exposure and positive outcome expectations
of taking action, then be confronted with a number of barriers that prevent him/her from actually
carrying out the desired behaviors.
Martinelli (2002) tested a model that included self-efficacy and outcome expectations
with mothers to prevent passive SHS and found that the model accounted for 32% of the
participants’ daily exposure to SHS (Martinelli, 1999l Martinelli, 2002). Having lower self-
efficacy to protect themselves from SHS and higher efficacy in protecting their children was
associated with greater exposure to SHS at home for both the mother and child. Since these data
were self-reports, it is thought that the mothers underestimated the children’s exposure and
objective measures are needed to assess the true severity of smoke pollution in residences. A
literature review of children’s exposure to SHS revealed that to prevent passive inhalation of
smoke, it is not necessary that the parents quit smoking, it is more important that the parents
have the skills and confidence for being able to address SHS (Arborelius, Hallberg, &

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Håkansson, 2000). However, a cross-sectional study in elementary schools in Taiwan showed
that children’s confidence in dealing with SHS was inversely related to number of smokers living
at home highlighting the inability of an individual’s power to deal with indoor smoke pollution
when there are more smokers around (Huang et al., 2012).
A pilot intervention comparing counseling geared towards first-hand smoke (FHS or
personal smoking) or SHS showed that the focus on SHS was more effective in helping smokers
quit than the intervention of FHS due to increased self-efficacy at post time (Schane, Prochaska,
and Glanz, 2013). In a similar approach with families in Indonesia, keeping a family safe from
smoke motivated fathers to agree to a community household ban, increasing the mother’s self-
efficacy in turn (Nichter, Padmawati, & Ng, 2010). An in-person training program of Hispanic
health promoters showed promise in improving self-efficacy for dealing with SHS, as they could
in turn educate the community (Rodriguez, Conway, Woodruff, & Edwards, 2003).
When a person to initiates an action, she typically has outcome expectations, which are
defined as the beliefs that a specific action will result in a particular outcome, positive or
negative (Bandura, 1997). Having rewarding expectations enhances the person’s desires to
engage in the behavior and having negative expectations can discourage the behavior. On the
case of SHS, if Hispanics think that asking a neighbor to smoke further away will cause
interpersonal problems between them, they will not take action (Delgado Rendon, Unger, Cruz,
Soto, & Baezconde-Garbanati, 2015). Results of a randomized controlled trial indicated that
parents who believed that THS was dangerous to their children’s health were more likely to
enforce home and car smoking bans than parents who did not (Jeremy E. Drehmer et al., 2014).
The decision-making process of whether to carry out an action or not is influenced by the
person’s perceived control of the outcomes (Bandura, 1997). Situational conditions can affect a

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person’s initiative to engage in protective ways against SHS. Bandura postulated that behavior is
the result of bidirectional interaction between the individual, the environment, and the behavior
itself, a term he referred to as reciprocal determinism (Bandura, 1977). This interaction is evident
when considering that apartment residents co-exist with other people in the same neighborhood
and are affected by the smoking policies in their cities. Barriers are the obstacles that people face
while attempting to perform a behavior while facilitators enhance the optimum conditions for
people to initiate and maintain healthy behaviors. Barriers may lower a person’s beliefs in their
capacity to attain the desired outcomes. For some people, barriers may involve lack of awareness
about the issue or how to solve it, inability to control the smokers’ behaviors, not having
smoking policies, managers who aren’t responsive, or social rejection by the smokers in the
community.
Collective efficacy expands the concept of self-efficacy to include a person’s perception
that a group of people can overcome challenges and achieve goals together (Bandura, 1995).
Successful groups of people are perceived to operate within their social systems to achieve
certain outcomes. The perception of collective efficacy can buffer stressors if individuals
perceive that the group makes decisions for the welfare of everyone involved. If people believe
that their apartment community can enact and enforce smoking rules for their own welfare, then
they will be more likely to brainstorm solutions together. Certain group characteristics could
enhance a person’s perception of their collective efficacy such as social cohesion and frequent
communication with their neighbors. Social cohesion is the willingness of the members of a
group to cooperate, create a sense of belonging and work toward the well-being of the group
members (Stanley, 2003). Residents’ feelings that their neighbors are supportive could increase a
person’s willingness to speak up about issues that concern themselves and other residents. For

21

the purposes of this study, we have incorporated collective efficacy and social cohesion to the
original Bandura’s causal model (Figure 2).
Observational learning is a cognitive process whereby the observer learns a new skill by
watching the role model. Bandura considered 4 factors for making an observational learning
health promotion activity more memorable: attention, information retention, motor production,
and intrinsic and extrinsic motivation (Bandura, 1977). Observational learning was instrumental
in the development of El Reto de Marta and its role is described in the methods section.
Fishbein included attitudes towards a behavior as part of the Theory of Reasoned Action
(TRA) to predict the likelihood of a person engaging in said behavior (Montaňo and Kasprzyk
2015). Instrumental attitudes, such as a resident’s evaluation of whether he should confront a
smoker is good or bad, could ultimately be related to his intention to take action.
Graphic Novels
SCT has guided health behavior interventions with graphic materials to promote
observational learning (Baranowki et al., 2002; Branscum, 2011; Leung et al., 2017; Liebman,
Juarez, Leyva, & Corona, 2007). Educational stories portrayed with pictures provide the
vicarious experiences for the readers to learn positive behaviors in an enjoyable way (Moyer-
Gusé, 2008). The process of developing the graphic novel El Reto de Marta was described in
previous publications and in the methods section of this article and was centered around role
modeling healthy behaviors (Delgado Rendon et al., 2015; Delgado-Rendon et al., 2017; Unger,
Soto, Baezconde - Garbanati, Delgado Rendon, & Cruz, 2019).
Storytelling is the oldest and most common communication method among humans
(Green et al., 2002). Written, visual, and audiovisual narratives are contemporary modes of
storytelling. These forms of entertainment education may improve attitudes by using the

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peripheral route of processing of information in the brain and bypassing the central route where
counter-arguing of persuasion occurs (Moyer-Gusé, 2008).
Most studies of graphic novels in health behavior studies do not use a theory to guide the
development or delivery of the intervention (Brannon, Wagstaff & Wagstaff, 1981; Chen and
Cheng Sim, 1986; Ingrand, Verneau, Silvain, Beauchant, & Poitou-Charentes, 2004; Prokhorov
et al., 2013). Among the published studies that mentioned SCT, only a handful actually evaluated
the relationship of SCT’s constructs with the health behavior outcomes (Cullen et al., 1998;
Harvey, 1997; Toroyan & Reddy, 2005). Branscum and colleagues evaluated an SCT based
comic book to teach elementary school children about nutrition and physical activity (Branscum,
2011). In the randomized controlled study, students received either an SCT guided comic book
or a knowledge-based intervention. Although they found improvements in some key measures of
fruit and vegetable consumption and engagement in physical activity, they did not find any
significant differences between the groups receiving the SCT intervention compared to the
knowledge-based interventions. It is possible that the intervention was not intensive enough to
result in long term positive changes that could be attributed to specific theory constructs. This
study also assessed changes in outcome expectations of eating five servings of fruits and
vegetables, engaging in physical activity, and sedentary behaviors but did not find any
differences between the intervention and comparison groups.
A study assessing the effect of an educational manga comic on youth’s healthy snack
eating was guided by the SCT (Leung et al., 2017). While they found changes in behaviors
immediately after reading the comic book, the researchers did not report an association between
specific SCT constructs, components of the educational material, and outcomes. The behavior
changes could have been temporary as data on long-term effects was not collected.

23

A mental health intervention utilizing a fotonovela for Latinas immigrants at risk of
depression did assess self-efficacy and found significant changes in their confidence to seek
treatment although actual appointment scheduling was not tracked in post measures (Hernandez
& Organista, 2013). Other interventions using graphic novels have included self-efficacy,
however they did not test its contribution to the effectiveness in improving health behaviors.
(Alcalay, Alvarado, Balcazar, Newman, & Huerta, 1999; Harvey, 1997; Jimenez, Reynolds,
Alegría, Harvey, & Bartels, 2015)
A comic book created to teach teenagers about the Human Papillomavirus Vaccine
(HPV) included instrumental attitudes about HPV because the authors believed that a realistic
story would successfully change the adolescents’ parents’ attitudes towards vaccination (Katz et
al., 2014). The comic book intervention yielded changes in vaccination attitudes, but not in
attitudes towards the barriers of accessing the vaccine. Another team of investigators tested a
comic strip’s influence on instrumental attitudes towards condom use and found that the comic
strip worked better than a text format of the same message to improve attitudes but only for the
participants who preferred low cognition (e.g. participants who prefer to use the peripheral route
of thought processing as opposed to the central route) (Carnaghi, Cadinu, Castelli, Kiesner, &
Bragantini, 2007). A study comparing three communication formats (video, comic, and group
education) found no changes on overall positive beliefs towards using a condom but did find
improvements for the video group in the belief that using a condom will prevent pregnancies
(Gillmore et al., 1997). A research study comparing a narrative version of an educational session
on cervical cancer was more successful at shifting the audience’s attitudes towards screening
procedures than its non-narrative counterpart (Murphy et al., 2013). Moreover, the Mexican

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American women identified more strongly with the Latin American characters of the story than
did European Americans and African Americans.
A fotonovela designed to improve knowledge and intentions of vaccination to human
papillomavirus (HPV) presented self-efficacy as role modeling (Chan, Brown, Sepulveda, &
Teran-Clayton, 2015). Highlighting protagonists who looked like the audience portraying the
desired behaviors contributed to improvements in the readers’ susceptibility to HPV and
intentions to get vaccinated. However, the researchers didn’t assess changes in self-efficacy post
exposure to the fotonovela. There has been contradictory evidence as to whether a narrative
format is better than a non-narrative format at persuading people to change their attitudes and
behaviors (Hinyard & Kreuter, 2007).
In the current study, the fotonovela El Reto de Marta – Marta on a Mission, used in one
arm of the intervention, was designed to encourage character identification with a role model,
which in turn can provide observational learning to aid in the development of self-efficacy.
There are unlimited ways in which a person can identify with an actor/actress playing a role such
as by: liking that character, wanting to be like him/her, feeling in the same crucible as they,
developing a para-social relationship with them, feeling the same emotions as the character, etc.
All of these forms of identification are ways of extending the perception of the self via empathy.
Studies conducted with video clips found temporary changes in the way the viewers defined
themselves (self-concept) stemming from higher character identification with the actors (Sestir &
Green, 2010). A Spanish language telenovela with incorporated messages about breast cancer
that was broadcast in a major television channel was shown to encourage Hispanics calls to a
help line during broadcast days (Wilkin et al., 2007). Character identification among the regular
viewers of this soap opera was associated with knowledge gains. A community based

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participatory research study in South Africa incorporated character identification in their
development of a photocomic to educate youth about AIDS prevention (Toroyan & Reddy,
2005). This collaboration project resulted in shifts in attitudes and improved intentions to change
behaviors. The current study compares the effects of a graphic novel that uses a role model
(Marta on a Mission) and a text pamphlet on residents’ attitudes, intentions and behaviors to
protect themselves and their family members against SHS/THS.

Research Aims and Hypotheses
This study assessed the associations between self-efficacy and collective efficacy on
protective attitudes and behaviors to prevent exposure to SHS, SHMS, and THS. A mediation
analysis was conducted to evaluate if SCT constructs mediated the associations between baseline
levels of protective attitudes and behaviors and follow up outcomes. To the authors’ knowledge,
no previous study has examined the relationships and effects of SCT constructs via a small print
educational intervention.
Figure 6. Scene from the fotonovela Marta on a Mission where the characters role model
discussing ways to protect apartment residents from SHS/SHMS.

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Exploratory Aim: The correlations and associations among Social Cognitive Theory constructs
and sociodemographic characteristics of the study groups will be explored.
Hypothesis 1: Self-efficacy (T1 and T2) and collective efficacy (T2) will be positively associated
with protective attitudes about SHS/THS (T2), favoring bans of SHSTHS (T2), and protective
behaviors related to SHS/THS (T2) among the participants in the fotonovela cohort.
Furthermore:
c) Self-efficacy (T1 and T2) will mediate the associations between protective attitudes (T1)
and behaviors (T2).
d) Self-efficacy (T1 and T2) will mediate the association between intentions (T1) and
behaviors (T2).
Table 1. Timeline of data collection and study measures.

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Hypothesis 2: Self-efficacy to protect self and family will be higher among the participants in the
fotonovela cohort than those of the comparison and control cohorts at follow up (Fotonovela >
Pamphlet > Control).
Hypothesis 3: The fotonovela will result in improvements in key outcomes about SHS/THS
(protective attitudes and behaviors) as compared to the other study groups. There will be
mediation effects of social cognitive theory constructs following Bandura’s integrated causal
structure (See Figure 9).
a) Positive outcome expectations (T2) will mediate the relationship between self-efficacy
(T1) and intentions to behave in protective ways (T2).
b) Collective efficacy (T2) will mediate the association between intentions to engage in
protective behaviors (T2) and behaviors (T2).
c) Self-efficacy (T1) will be positively associated with protective behaviors (T2)
d) Positive outcome expectations (T2) will be positively associated with protective
behaviors (T2).
e) Negative outcome expectations (T2) will be negatively associated with intention to
engage in protective behaviors (T2).
Figure 7. Conceptual framework for study 2.

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f) Self-efficacy (T1) will be negatively associated with barriers (T1)
g) There is a dosage effect as in the number of self-reported barriers to engage in protective
behaviors (T1) will be negatively associated with intentions (T1 and T2).

Methods
Development of the Fotonovela
The intervention was developed following SCT (Delgado-Rendon et al., 2017; Unger et
al., 2019). After a series of revisions, a list of messages was assembled in Broadcast American
English and translated into Broadcast Latin American Spanish. The imagery and dialogue
contents were guided by SCT constructs and resulted on a draft fotonovela that was pre-tested a
few times with people matching the intended audience’s culture and demographic characteristics
for relevance, comprehension, and reactions to cues to action. This reiterative process assured the
research team that the final version of the fotonovela was appropriate for mass printing and
testing.
Marta on a Mission provides role modeling (self-efficacy construct) for the appropriate
ways for the Hispanic tenants to protect themselves from environmental smoke. The main
characters represent the peripheral and socio-cultural characteristics of a typical Hispanic family
Figure 8. The study model was guided by Bandura’s integrated causal structure of social
cognitive theory from self-efficacy to behavior (Bandura, 1998).

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living in Los Angeles (Kreuter, Lukwago, Bucholtz, Clark, & Sanders-Thompson, 2003). In
some scenes Marta role models how to communicate with her family and neighbors about SHS.
The fotonovela also depicts ways in which the MUH tenants can increase their collective
efficacy by coming together to solve the differences in opinions about SHS among non-smoking
and smoking tenants by creating rules and smoking zones. The storyline catches the audience’s
attention by posing a dramatic situation of Marta’s son’s visit to the emergency hospital.
Intertwining jokes and secondary plots help maintain the readers’ interest in the story through to
the end. El Reto de Marta - Marta on a Mission is a photorealistic story that lends the audience
vulnerable to transportation and parasocial interaction effects worthy of further examination. The
pictures help the audience visualize the positive outcomes of taking the initiative to address SHS
in their communities (Bandura, 1997).
Sampling and Data Collection
This analysis is drawn from a survey of Hispanic tenants of MUH in the Los Angeles
area in 2014. Participants were Hispanic adults living in randomly selected MUH units in eastern
metro Los Angeles. The sampling procedure has been published previously (Delgado-Rendon et
al., 2017; Unger et al., 2019). This is a study with a pre/post prospective three-group design with
random assignment of participants to one of three intervention groups. The treatment group
received the fotonovela Marta on a Mission, the comparison group received the Tobacco
Education Clearing House of California Catalogue (TECC) educational pamphlet in non-
narrative format, and the control group did not receive any educational materials (California
Department of Public Health, 2007; Unger et al., 2014). The participants were randomized to one
of the groups by building to avoid contamination. Participants completed a baseline survey,
received the material, and completed a post-test 6 months later. A total of 337 participants

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completed the post survey, 115 in the fotonovela group, 108 in the pamphlet group, and 114
control group.
Measures
Demographic characteristics included age, sex, ethnicity, years of education, and
preferred language for completing the survey. Household characteristics included number of
residents in the unit. Social Cohesion consisted of five statements at the follow-up survey asking
the respondent how strongly they felt the neighborhood was close-knit and supportive.
Communication with neighbors was a single item rating between 1 and 10 from least frequent to
very frequent interaction with neighbors.
Elements of Social Cognitive Theory were adapted from general self-efficacy, collective
efficacy, barriers, and outcome expectations questions (Kelder, Hoelscher, Perry, 2015). These
items were included in the baseline and post surveys. The self–efficacy scale contained 7 items
rating participants’ confidence that they could protect themselves and their families from
exposure to SHS and THS at home and around the building property (baseline a=0.75, post
a=0.73). The intentions to protect themselves against smoke exposure scale included three items
on whether the residents planned to talk to their landlord and neighbors about SHS and THS
(baseline a=0.83, follow up a= 0.81). Perceived barriers to protect themselves from SHS
included nine barriers selected a priori by the research group: “I can’t control other people’s
actions,” “I don’t feel comfortable telling people not to smoke,” and “The manager is not
helpful,” among others (baseline a=0.74).
Collective efficacy was measured in the follow-up survey using three items such as “My
neighbors and I could convince our landlord to make a smoke-free rule” (baseline a=0.91).
Positive and negative outcome expectations of the residents’ communication with managers and

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neighbors were incorporated with four possible responses such as “Manager would not pass a
rule”, “Manager would make a smoking area away from the living spaces”, “Manager would not
do anything”, and “Manager would ask the city for help in passing a rule” (Positive outcome
expectations at follow up a=0.75, negative outcome expectations at follow up a=0.81).
Outcome Measures included support for a smoke-free building policy (tobacco only or
tobacco, marijuana, and e-cigarettes), protective attitudes (overall attitudes composed of three
subscales), and behavior to protect themselves and their families from smoke exposure (scales
were described in previous publications) (Delgado-Rendon et al., 2017; Unger et al., 2019). The
three subscales of protective attitudes include attitudes towards talking with others, attitudes
towards moving out of the building rather than confronting the issue, and attitudes towards
setting a smoking area.
Statistical Analysis
Data was cleaned and cleared of errors in Stata. Analyses were conducted with Stata
13.0® (StataCorp, 2013). Group size was calculated prior to collecting the data to achieve
enough power for the analysis. These analyses examined the distribution property of the
variables and were found to exhibit normal distribution. Descriptive analysis on the baseline and
post surveys has already been presented (Summary in Table 7) (Delgado-Rendon et al., 2017;
Unger et al., 2019) The responses to the Likert-type questions were reversed scored as needed
prior to computations. The totals were summed to yield cumulative scores for scales and
subscales. The data was divided by the treatment received (fotonovela, pamphlet, no material). In
the numerous studies that assessed self-efficacy mentioned in the introduction, self-efficacy was
used as a predictor, mediator, outcome, or all of the above. In this study, self-efficacy was

32

evaluated as a predictor, mediator, and outcome to better understand its role in the cognitive
processes involved. P-values of 0.05 were considered statistically significant.
Exploratory Aim. Intercorrelations were used to examine the relationships including
demographic characteristics, neighborhood characteristics, and theoretical constructs. A separate
examination of the relationships among the variables included multivariate analyses between key
demographic, theory constructs, and outcome variables to assess for confounding and interaction
effects. Demographic characteristics used as covariates in the analysis: age, sex, formal years of
education, and preferred language. Predictor variables consisted of intervention group, self-
efficacy, outcome expectations, social cohesion, intentions to engage in protective behaviors
related to SHS/THS/SHMS, and barriers to engaging in desired actions. Outcome variables were
attitudes and protective behaviors about SHS/THS/SHMS.
Hypothesis 1. Multivariate regressions were conducted to assess the associations
between self-efficacy and collective efficacy with protective attitudes, favoring bans, and
protective behaviors. Both unadjusted and adjusted regressions were carried out to account for
age, sex/gender, and language. Baseline levels of self-efficacy (T1) and changes of self-efficacy
(T2-T1) were assessed to evaluate the effect of this construct as a predictor and as a process
variable. Cross sectional multivariate regressions of SCT constructs and outcomes measured at
follow up were carried out. Collective efficacy was only collected at follow up and thus can only
be assessed as a mediator or process outcome.
Hypothesis 2. Multivariate linear regression models were used to assess if changes in
self-efficacy in the fotonovela group were better when compared with the text pamphlet and
control groups at follow up (Fotonovela > Comparison Pamphlet > Control). Group placement

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was the independent variable and changes in self – efficacy (T2 – T1) was the dependent
variable. Important covariates were age, sex/gender, and language.
Hypothesis 3. Paired t-tests were used to assess the within subjects’ differences at follow
up compared to baseline for SHS/THS (protective attitudes and behaviors) for the three study
groups. Mediation effects of social cognitive theory constructs (Hypothesis 3 a-g) guided by
Bandura’s integrated causal structure were assessed following Baron and Kenny’s step analysis
(Baron & Kenny, 1986). First, the potential mediator was regressed on the predictor variable (a).
Second, the outcome is regressed on the mediator (b). Third, the outcome variable was regressed
on the predictor variable (c). Fourth, the outcome variable was regressed on both the predictor
and mediator variables (d). If the regression coefficients of a, c, and d are statistically significant,
the mediator variable is said to mediate or partially account for the association between the
predictor and outcome variables. Mediation path regression coefficients were reported along with
statistical significance and are detailed in a proposed model (Figure 10).
Results
The final cohort consisted of 337 people who completed the baseline and follow up
surveys (See Table 2). Women represented 75% of the sample and 62% spoke Spanish. Mexican
ethnicity accounted for 65% of the participants, mestizos making up the most common racial
category. On average residents had 10.8 years of education, 37% had less than a high school
degree. Although only 3.6% of the residents allowed smoking inside their units and 94% had
apartment building smoking bans, 69% reported smelling SHS and 46% smelled SHMS.
Characteristics and assessment scores of the sample per treatment condition are presented in
Tables 2 and 3.

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Table 2. Participant characteristics per treatment condition.

Table 3. Participants’ scale scores per treatment condition.

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Exploratory Aim.
The relationships between social cognitive theory constructs and characteristics of the
target group were explored (Both at T1 and T2). Zero-order correlations among study variables
revealed interesting associations (See Table 8). Older individuals reported having more frequent
communication with neighbors (r=0.16, p£0.01), which in turn was associated with better
collective efficacy (r=0.23, p£0.01), social cohesion (r=0.20, p£0.01), and engaging in protective
behaviors (r=0.30, p£0.01). However, older age was also related with reporting facing more
barriers to protect themselves from SHS/SHMS/THS (r=0.19, p£0.01). There was a significant
correlation between intentions to engage in protective behaviors at baseline and protective
behaviors at post-time (r=0.36, p£0.01). Frequency of communication with neighbors was
significantly associated with all of the SCT constructs and neighborhood characteristics except
baseline self-efficacy. As expected, positive outcome expectations were positively related to the
beneficial variables (collective efficacy and behaviors), and both negative outcome expectations
and barriers were negatively associated with those same variables.
Table 4. Intercorrelations among study variables including the demographics of the study group, social
cognitive theory constructs, and characteristics of the apartment communities (social cohesion and
communication among neighbors).

36

Further exploration of the associations among constructs and sociodemographic variables
revealed interesting contributions of covariates (Table 9). Multivariate linear regressions of key
outcomes at follow up (Time 2) revealed several potential explanatory models. For the
fotonovela group, self-efficacy, collective efficacy, and favoring bans were significantly
associated with age, gender, language, social cohesion, barriers, positive outcome expectations,
and negative outcome expectations. For the pamphlet group, self-efficacy, protective attitudes,
and favoring bans were significantly associated with age, gender, language, social cohesion,
barriers, positive outcome expectations, and negative outcome expectations. Communication
with neighbors was not included in the models due to its collinearity with all the other variables
of interest. The most frequent and significant contributing variables to these models were
language (Spanish) and positive outcome expectations.
Hypothesis 1.
Looking at self-efficacy (SE) as a predictor, a small but significant relationship was
detected between baseline SE and favoring smoking bans at follow up for both unadjusted
(b=0.21, R
2
= 0.05, p£0.01) and adjusted for covariates of age, sex, and language (b=0.26, R
2
=
0.18, p£0.00). Paired t-tests did not reveal positive improvements in self-efficacy or protective
attitudes from baseline to follow up among the three study groups. Even though, paired t-tests
did not show improvements in these constructs, we proceeded to conduct regression and
mediation analyses with SE as a predictor, mediator, or outcome and attitudes as mediator or
outcome associated with the other SCT constructs and neighborhood characteristics. Paired t-
tests showed improvement in favoring tobacco bans comparing baseline and follow up scores in
the pamphlet group (p=0.01). Intentions to engage in protective behaviors improved in the

37

fotonovela and pamphlet cohorts but not in the control (T2 – T1, p=0.03 and p=0.03
respectively).

Table 5. Cross-sectional associations of key outcomes at follow up and social cognitive theory constructs
adjusted by covariates of importance.

38

Higher levels of self-efficacy (T1 and T2) and collective efficacy (T2) were expected to
be associated with better protective attitudes, favoring bans, and protective behaviors at follow
up among the participants in the fotonovela cohort. No significant relationships were found
between total changes of self-efficacy (SE T2 – SE T1) and overall attitudes, favoring smoking
bans, and protective behaviors. Change of SE was positively related to the attitudes about talking
with neighbors at follow up in the unadjusted model (b=0.11, p£0.02), but not when adjusting
for covariates.
No significant relationships were found between collective efficacy (T2) and overall
attitudes and favoring bans. Collective efficacy (T2) was significantly associated with protective
attitudes about talking with neighbors for both unadjusted (b=0.34, R
2
= 0.25, p£0.01) and
adjusted for covariates of age, sex, and language (b=0.35, R
2
= 0.26, p£0.00). A modest positive
association of collective efficacy (T2) and protective behaviors (T2) was found for both
unadjusted (b=0.15, R
2
= 0.05, p£0.02) and adjusted for covariates of age, sex, and language
(b=0.16, R
2
= 0.09, p£0.05).
Hypothesis 2.
Changes of self-efficacy (SE T2 – SE T1) were not found to be higher among the
participants in the fotonovela cohort than those of the comparison and control cohorts. Collective
efficacy was only collected at follow up. There was no difference in scores of collective efficacy
(T2) between the three study groups.

39

Hypothesis 3.
The fotonovela was hypothesized to result in better outcomes about SHS/THS as
compared to the other study groups (pamphlet and no material). There was no difference in self-
efficacy and attitude change (T2-T1) in scores from baseline to follow up across the three
groups. The pamphlet group had a better improvement in favoring tobacco bans than the
fotonovela group (Scheffe test, p = 0.03). There was a significant difference in protective
behaviors at follow up; the two intervention groups had better protective behaviors than the
control group (Anova test, p=0.04). The mediation effects of social cognitive theory were
examined following Baron and Kenny’s causal mediation steps to assess Bandura’s integrated
causal structure for the fotonovela study group (See Figure 2) (Baron & Kenny, 1986). The
mediation analysis in this study included the following equations:
a. M = i1 + aX + e1
b. Y = i2 + bX + e2
c. Y = i3 + cM + e3
d. Y = i4 + dX + bM + e4
Table 6. Association of changes in self-efficacy by intervention type; fotonovela, pamphlet, no
material revealed no statistically significant relationship (All three groups, n = 313). The control
condition is the reference group.

Legend: M is mediator, i is the intercept, aX is the coefficient of
the independent variable, bX is the coefficient of the mediator, cM
is the coefficient of the mediator on its own, dX is the coefficient of
the independent variable when the dependent variable is controlled
by both the independent variable and mediator.

40

Self-efficacy (T1) did not mediate the associations between protective attitudes (T1) and
protective behaviors (T2) among the fotonovela readers. When controlling for self-efficacy, the
relationship between attitudes and behaviors was not statistically significant (bd = 0.05, p=0.42).
Self-efficacy (T1) partially mediated the association between intentions at baseline (T1) and
behaviors (T2) (ba = 0.27, p=0.00, bb = 0.05, p=0.42, bc = 0.19, p=0.00, bd = 0.18, p=0.04). The
mediation of positive outcome expectations (T2) on the association between self-efficacy (T1)
and behaviors (T2) was not statistically significant (bd = 0.02, p=0.73).

Collective efficacy (T2) successfully result in a partial mediation effect of intentions (T1)
on protective behaviors (T2) (ba = 0.29, p=0.03, bb = 0.33, p=0.02, bc = 0.82, p=0.00, bd = 0.17,
p=0.00). Collective efficacy (T2) also resulted in a partial mediation effect of intentions at follow
up (T2) on protective behaviors (T2) (ba = 0.43, p=0.00, bb = 0.33, p=0.02, bc = 0.21, p=0.00, bd
= 0.21, p=0.00). Collective efficacy (T2) was not tested for any other mediation effects besides
behavior (T2) since it did not meet the criteria for being a precursor to the variables collected at
baseline. A proposed model of the causal structure from self-efficacy (T1) to protective
behaviors of SHS (T2) for the fotonovela group of this study is based on the associations among
key SCT constructs and mediation analyses performed (See Figure 10).
Figure 9. Mediation path of self-efficacy on the path between intentions to behave and
engaging in protective behaviors (Fotonovela Group, n =112).

41

Discussion
There were several significant correlations among the variables included in this study.
Hispanics who lived in neighborhoods with high levels of social cohesion, frequent
communication among neighbors, and fewer barriers were more likely to protect themselves
against SHS exposure and to correlate with positive SCT constructs. While this study design
does not allow us to assess causation, these neighborhood traits of social cohesion and
communication would be important to acknowledge and facilitate through planned neighborhood
events. In order to use self-efficacy and collective efficacy as a mechanism to stop SHS in multi-
unit housing properties, for some communities that lack those positive traits it is advised to
increase the neighborhood trust, cohesion, communication, and reduce pre-existing barriers as
part of any long-term plans. Secondhand smoke being an interpersonal issue by nature, these
social conditions must be helped in the process.
Figure 10. Final two separate mediation paths based on the current study analyses that follow part of
Bandura’s integrated causal structure of social cognitive theory from self-efficacy to deal with SHS to
engaging in protective behaviors against exposure to SHS. Following Bandura’s structure, positive outcome
expectations was significantly associated with engaging in protective behaviors at follow up (e).

1
The mediation path model 1 (Self-efficacy à Positive outcome expectations à Intentions) was statistically
significant, but the self-efficacy coefficient was not.

42

Multilinear regressions of the key outcomes showed that language (Spanish) and
positive outcome expectations were more likely to be a significant variable in the models
predicting the outcomes measured at follow up (self-efficacy, collective efficacy, protective
attitudes, and behaviors) in the models across the three study groups (See Table 5). Participants
who prefer to speak Spanish are more likely to support all types of smoking bans in the
properties than Hispanics who are more English dominant, yet at the same time Spanish speakers
also tend to have lower protective attitudes. On the surface this discrepancy between low
attitudes and favoring rules might look contradictory, however, it supports previous evidence that
Hispanics prefer to avoid interpersonal issues with smokers and managers as much as possible,
thus, enacting and enforcing smoking policies at the community level is preferred over individual
level interventions (Delgado Rendon et al., 2015; Delgado Rendon et al., 2019).
Although there were no overall improvements in self-efficacy nor total protective
attitudes in the study groups, some associations are worth discussing. Self-efficacy changes (T2-
T1) in the fotonovela group were positively associated with the sub score of attitudes about
taking action and talking with their neighbors. Baseline levels of self-efficacy of the fotonovela
group was strongly associated with favoring all types of bans (T2) even after adjusting for
covariates. Bandura speculated that people who have built some basic skills related to the issue at
hand have laid the ground for better self-efficacy and this in turn improves their attitudes towards
problem solving processes since they feel more confident about their abilities to work through
the issues. The results of these analyses point towards the strength of these relationships but do
not clarify the direction. While self-efficacy (T2-T1) scores were not higher among the
participants in the fotonovela cohort than those of the comparison and control cohorts, it does not
mean that the educational materials did not have an effect on this construct. Rather, it is possible

43

that as explained earlier, there are other factors to consider such as the study design and
neighborhood characteristics. For example, including landlords, apartment managers, and city
councils into the design, implementation, and evaluation of such programs might make a positive
effect in the tenants’ collective efficacy. Timing the intervention with new smoking policy
implementation and enforcement and enhancing facilitating factors can contribute more to
people’s self-efficacy than only a communication campaign.
Collective efficacy (T2) was strongly associated with protective attitudes about talking
with neighbors (T2) among the readers of the fotonovela even after adjusting for covariates. This
model accounted for 26% of variation of the attitude sub scores at post time indicating the
psychosocial connection between perceived collective confidence in addressing issues and
attitudes towards talking with people about a specific issue. As hypothesized, collective efficacy
(T2) was positively associated with protective behaviors (T2) among the participants in the
fotonovela group, since the behaviors are necessary to deal with SHS are interpersonal.
Mediation analysis following Baron and Kenny’s step approach showed a plausible
mechanism for attaining the desired outcomes using Bandura’s integrated causal structure (See
Figure 10). Positive outcome expectations turned out to be more important than negative
outcome expectations in mediating the association between self-efficacy (T1) and intentions
(T2). Future educational interventions could emphasize positive over negative outcomes to
improve behaviors. It is impossible to attest causation among these variables; other pathways are
possible as there were significant mediation paths that differed from the one here proposed.
Future studies should tease these associations apart and finalize the most cohesive model.

44

Limitations
Part of the outcomes rely on the participants’ recollection of the information imparted;
the post – survey data was collected 6 months after exposure to the educational materials which
may result in poor recall. Nonetheless, we gained insight into the mechanisms of how social
cognitive theory can impact outcomes of tobacco education. It is also possible that some adults
did not take an entertainment material as seriously as the booklet produced by the California
Department of Public Health. Hence, both text heavy and entertaining materials should be used
by residents according to their preferred ways of processing information (i.e. central or
peripheral).
The study design lends itself to internal validity weaknesses; the baseline survey items
alerted the participant of the messages to be imparted and may have implicitly changed their
focus while reading the intervention and comparison materials. Other internal validity
weaknesses could be maturation and the interaction between the selection of participants and
maturation. The first potential issue with external validity is the sampling of participants. Study
participants were pooled from a selection of multi-unit housing buildings at risk of exposure to
SHS/THS. Participants were identified using the Census tracts from the 2010 Census and were
selected if they were living within a 15-mile radius of East Los Angeles and at a neighborhood
with at least 80% Hispanic residents. Although the Marta fotonovela cohorts provided a unique
opportunity given the participants’ residence locations and randomization over the County of Los
Angeles, a few limitations with this sampling method are worth noting. First, the data collectors
had to get access to the units in order to reach tenants, therefore, it would be easier for outsiders
to reach the same properties and smoke than in gated communities. Therefore, the results may
only be generalizable to open buildings and not generalizable to gated communities. Second of

45

all, the tenants had to be present and while the data collectors worked during the day hours for
security reasons, it was likely that these tenants were not otherwise employed. Third, the
participants agreed to participate and therefore self-selected to join the study. Given that they
knew the study was about secondhand smoking, smokers may have been less likely to join than
non-smokers and people interested in addressing the issue of environmental smoke in their
neighborhoods. On the plus side regarding ethnic background, the final sample had 64.3% people
of Mexican descent and 33.3% were people from other Latin American countries, reflecting a
similar variety of subgroups of Hispanics in other locations in the Southwest of the United
States. The median annual household income was $20,000 - $29,000, which could make the
results partially generalizable to non-Hispanic low income MUH residents. Smoking laws vary
across states and cities; however, California is known to have the most progressive policies.
Therefore, the results may be generalizable to locations with similar smoking rules in apartment
buildings but not equally across the U.S.
Conclusions
A potential model of the causal structure from self-efficacy to protective behaviors of
SHS is proposed. Neighborhood characteristics of social cohesion and frequency of
communication with neighbors and manager are important factors associated with stronger
collective efficacy for addressing SHS. Therefore, they would be helpful to encourage when
designing interventions to decrease SHS pollution in shared and open spaces. Health
professionals and policy makers should consider including the components of this model for
future plans of addressing exposure to tobacco, marijuana, and e-cigarette smoke in shared living
spaces (See Figure 10). Health communication campaigns are limited to the effect of raising
awareness about the issue, environmental and neighborhood barriers to assist residents in their

46

efforts to prevent SHS need to be addressed separately. Future research is needed with a larger
sample and theory data collected at baseline to test the model in its entirety using other statistical
methods such as structural equation modeling.

47

Chapter 3. The Role of Health Literacy in a Bilingual Educational Intervention for the
Prevention of Secondhand Smoke among Hispanics
Introduction
Interventions for Prevention of Secondhand Smoke exposure
Exposure to Secondhand Smoke (SHS), Secondhand Marijuana Smoke (SHMS), and
Thirdhand Smoke (THS) in multi-unit housing is a threat to public health. One in four non-
smokers older than 3 years of age is exposed to SHS (Homa et al., 2015). Although Hispanics
have lower rates of tobacco smoking overall, lower income Hispanics who live in apartment
buildings have a higher risk of exposure to smoke than European-Americans (Baezconde-
Garbanati et al., 2011; Cook et al., 2014; Escoffery et al., 2013). Exposure to SHS for people
residing in apartment buildings is higher than in single homes, and while home smoking bans
minimize exposure from indoor sources, it is challenging to control the penetration of SHS/THS
from outdoor sources (Nguyen, Gomez, Homa, & King, 2016). Health consequences of SHS
include cancer, cardiovascular diseases, respiratory diseases, strokes, and developmental harm to
fetuses and newborn infants (Merritt & lekarski, 2012; U.S. Department of Health and Human
Services, 2014). Much of the exposure is at home, rather than work (U.S. Department of Health
and Human Services, 2014).
In a qualitative study conducted in Houston and San Diego (Savas et al., 2017). Mexican
Americans encountered various barriers to implementing and enforcing smoking bans in single
homes such as relatives and guests who smoke, family dynamics, and lack of access to
information in Spanish. Some cultural values such as familismo facilitated protection against
smoke while others such as respeto for the smokers impeded the adoption of smoke free rules
(Baezconde-Garbanati et al., 2011; Unger et al., 2019). Children can be a motivating factor for

48

families to turn their homes into clean air spaces (Gonzales, Malcoe, Kegler, & Espinoza, 2006).
It is also important to highlight the importance of smoking bans in the properties even when
children are not present to prevent the accumulation of residual tobacco smoke. Respeto and
interdependence highlight the importance of accommodating the needs and wants of others,
including smokers (Delgado Rendon et al., 2015). Invidualists tend to be less concerned with
saving face and maintaining harmony with people around them than collectivists and may be
more likely to confront smokers to protect themselves from contamination (Olekalns, 2015).
Interventions for the prevention of SHS and THS for Hispanics have primarily focused
on the adoption of home smoking bans and protection of family members with respiratory
conditions (Blaakman et al., 2015; Hovell et al., 2002). A pilot study that included Hispanics
utilized motivational interviewing counseling to persuade parents of premature babies to adopt
smoke free rules at home and yielded improvements in clinical outcomes such as more smoking
bans indoors and less children’s exposure to SHS (Baezconde-Garbanati et al., 2011; Blaakman
et al., 2015). Non-clinical interventions such as educational campaigns can also combat exposure
to SHS, SHMS, and THS in apartment buildings (Rosen, Myers, Winickoff, & Kott, 2015). By
educating vulnerable populations about the health and economic problems caused by SHS,
residents might act to protect themselves and their communities. Future educational interventions
that focus on SHS and THS should include new tobacco products such as electronic cigarettes
and marijuana since these are becoming more prevalent and are not regulated equally as tobacco
smoking (Barry et al., 2014).
Health Literacy
Health literacy is the “degree to which individuals have the capacity to obtain, process,
and understand basic health information and services needed to make appropriate health

49

decisions” (Nielsen-Bohlman & Institute of Medicine, 2004). It is considered a mediator between
patients and their medical outcomes because low health literacy is a barrier in doctor-patient
communication (Cooper Jr. et al., 2018; Freebody & Luke, 1990; Waldrop-Valverde, Jamale
Murden, Guo, Holstad, & Ownby, 2018). There are two ways to bridge the health literacy
barrier: 1) by tailoring informational materials to a reading level appropriate for a general
audience, and 2) by identifying participants with inadequate health literacy and providing them
with the resources necessary to comprehend the medical information.
Among Hispanic immigrants, low English health literacy (EHL) is associated with
poverty, not having health insurance, and with worse health outcomes (Becerra, Arias, &
Becerra, 2017). In California, Hispanics with low health literacy were more likely to have
limited English-speaking proficiency (Becerra et al., 2017). Studies have also shown a disparity
in terms of smokers’ reading capacity and the reading level of smoking educational materials
(Meade & Byrd, 1989). Attempting to function in a different cultural context is hard enough for
apartment dwellers; further exacerbating the stressful situation of dealing with smokers is
enduring literacy barriers to get information. Previous studies revealed that Hispanic community
members identified a need for medical information without jargon, better Spanish translations,
less complicated terms, and an interesting style (Sberna Hinojosa et al., 2010). Hispanics can
have different language fluency and reading abilities in Spanish and English, varying from being
monolingual to fully bilingual. Monolingual Spanish speakers tend to report lower health literacy
than bilingual or monolingual English-speaking Hispanics (Sarkar et al., 2016). Hispanics with
higher English literacy reported better health status (Prins & Monnat, 2015). A literature review
of Hispanics’ health literacy revealed that researchers did not always define or operationalize
health literacy and did not use validated measures of literacy in Spanish (Koskan et al., 2010).

50

The same review showed that most researchers do not report the literacy level of the materials
used in their interventions. These gaps warrant more tailored communication campaigns that
adequately match the tenants’ literacy levels, health knowledge needs, and learning styles.
Graphic Novels
The problem of low health literacy calls for appropriate health communication methods
to help make informed choices about health care. Conventional health interventions have used
the analytical approach by presenting statistical evidence and logic to persuade them to change
their behavior (Hinyard & Kreuter, 2007; Slovic et al., 2004). One promising communication
method that may aid people with low health literacy would use a narrative system that includes
storytelling, testimonials, and graphic narratives. People exposed to narrative forms of
communication have been shown to be more receptive to health messages than people exposed to
non-narrative videos (Murphy et al., 2013).
A narrative is a story, written, verbal, or visual (with graphics or pictures) which connects
a series of events (Green et al., 2002). Some forms of graphic narratives are fotonovelas (picture
book with a story), comic strips, comic books, and manga -Japanese style comic books
(Branscum, 2011; Furuno & Sasajima, 2015; I. Ingrand et al., 2004; Valle et al., 2006).
Fotonovelas are a type of graphic novel that originated in Latin America and show promising
results in improving awareness of health issues and desired preventive behaviors when used in
public health campaigns (Butler Flora, 1980; Koops Van’t Jagt et al., 2018; Sberna Hinojosa et
al., 2010; Unger et al., 2009; Valle et al., 2006). Containing pictures and a brief amount of text,
fotonovelas may counteract literacy and cultural barriers (Cabassa, Molina, & Baron, 2012;
Sberna Hinojosa et al., 2010). The use of graphics may lower the reading requirement of
educational material, making easier for the reader to derive the meaning of the messages from

51

the context of the pictures, facial expressions of the characters, signs of sounds, brief amount of
text, and a variety of other visual cues.
Most of the studies on graphic novels do not identify mechanisms that make these
graphic tools effective nor their effectiveness in overcoming literacy obstacles (Cabrera,
Morisky, & Chin, 2002; Chan et al., 2015; Jimenez et al., 2015; Peres, Moreira, Fau - Rodrigues,
Rodrigues, Claudio, & Claudio; Redmond, Hamilton, Kay, Worthington, & Blinkhorn, 2001).
Only one study has assessed the effects of a graphic narrative intervention on the SHS exposure
of Mexicans in single family homes (Prokhorov; et al., 2013). The researchers found significant
changes in smoking behavior (parents consumed cigarettes outside the home instead of inside the
home) using culturally appropriate comic books and fotonovelas between the intervention and
control groups. However, the fact that they installed an ambient air monitor in the participants’
homes to measure changes in ambient nicotine levels might have confounded the results because
the participants knew the air quality of their homes was being measured. No such study has been
conducted in a multi-unit housing setting.
Other studies comparing graphic novels with non-narrative forms of education have
revealed conflicting results as to the benefits of using more pictures than written messages
(Gillmore MR et al., 1997). We conducted a review of the use of graphic novels in health
behavior interventions revealed that out of 53 studies, only 1 study formally assessed and
reported the literacy level of the participants (2%), 7 assessed it informally or didn’t clearly
specify the test used (13%), and 45 (85%) did not assess it nor report it in their findings (Chan et
al., 2015; Hernandez & Organista, 2013; Unger et al., 2009; Valle et al., 2006). While
educational level has been used as a proxy for reading comprehension, it is not an accurate
estimate of people’s actual understanding of the health messages imparted. The overwhelming

52

majority of the studies using graphic materials noted the main reason for using tools with
pictures was to overcome the literacy barriers of their target populations but did not actually
measure the literacy level of the materials nor or evaluate their effect on participants with low
literacy.
Some of the studies previously mentioned filled in gaps about the potential benefits of
using graphic novels to educate the public about important health issues and also highlight the
need to more accurately assess the effect of health literacy in health education (Prokhorov; et al.,
2013). Text heavy materials may require the reader to have higher health literacy to process their
content than graphic novels, in which case fotonovelas may overcome literacy barriers to
communicate health messages effectively. Research is needed to understand the role of the
participants’ health literacy and readability level of the materials in outcomes after exposure to
the educational tools.
Research Aims and Hypotheses
This study examined whether the participants’ levels of health literacy moderate the
association between type of material (fotonovela, pamphlet, no material) and changes in
knowledge, attitudes, and protective behaviors to SHS, SHMS, and THS (Figure 5). This is the
first randomized study to assess the relationship between apartment residents’ health literacy
levels in either English or Spanish on the outcomes of different educational materials for the
prevention of SHS/SHMS/THS.
Exploratory Aim: The correlations and associations among health literacy, outcomes, and
sociodemographic characteristics of the study groups were explored.

53

Hypothesis 1: The outcomes of the fotonovela and pamphlet groups will be weaker for
participants with low English health literacy and Spanish health literacy for people with high
English health literacy and Spanish health literacy.
Hypothesis 2: The association between baseline (T1) and follow up outcomes (T2) will be
moderated by levels of EHL/SHL when stratified by primary language for both fotonovela and
pamphlet comparison groups (Separate participants by the language they preferred for
completing the survey into English and Spanish speaking groups).
c) Among participants who prefer to speak Spanish: Health literacy in Spanish will
moderate the association between educational material and outcomes (knowledge,
protective attitudes, favoring bans, and protective behaviors).
d) Among participants who prefer to speak English: Health literacy in English will moderate
the association between educational material and outcomes (knowledge, protective
attitudes against exposure to SHS, favoring bans, and protective behaviors such as
speaking with the manager or neighbors about addressing exposure to SHS.
Methods
Our team of investigators produced the fotonovela Marta on a Mission – El Reto de
Marta (Figure 11) (Delgado-Rendon et al., 2017; Unger et al., 2014). This graphic tool was
created by a team of researchers, a producer, and art professionals. The content and script were
derived from a series of focus groups conducted prior to the start of the study (Delgado Rendon
et al., 2015).

54

Messages in the graphic novel were based on these focus groups results about challenges
and opportunities for changing exposure to SHS. The research team organized these factors,
using the Social Cognitive Theory (SCT) constructs of self-efficacy, collective efficacy,
observational learning, outcome expectations, and behavioral capability (Kelder, Hoelscher,
Perry, 2015). The script was developed in consultation with bicultural research staff, first in
broadcast American English and subsequently translated into broadcast American Spanish.
Broadcast language of a media product is the version of a language which is understandable to
the majority of the audience without any regional words or phrases that differ among groups. The
storyline presents accurate information about the health risks of exposure to SHS, and THS and
Figure 11. Sample pages of El Reto de Marta (Marta in a Mission).

55

briefly mentions SHMS as a potential risk in the question and answer section at the end of the
story. The reading level of the story was below 8
th
grade reading level in both English and
Spanish, using the SMOG Grading Readability Formula (Contreras, Garcia-Alonso, Echenique,
& Daye-Contreras, 1999). Pilot testing of the materials with a few members of the target
audience confirmed that the fotonovela was easy to understand at that literacy level. Characters
appealed to the audience with ethnically familiar Hispanic appearance and Los Angeles scenery
(Kreuter et al., 2003). The fotonovela presents a Hispanic family experiencing problems with
smoke in a multi-unit housing property. The mother, Marta, takes the initiative to keep her
family safe from smoke after her son is diagnosed with asthma. She embarks on a mission to
gather support from her neighbors to establish clean air and smoking zones. Problem solving
techniques are modeled by Marta in collaboration with a health care provider, her family, and
neighbors (Figure 5).
The text pamphlet used in the comparison condition was Secondhand smoke and
apartments, condos and townhouses from the Tobacco Education Clearing House of California
Catalogue (TECC), a 17-page low-literacy text booklet about the dangers of SHS, ways to reduce
SHS exposure in apartments, steps for promoting smoke-free policies in multi-unit housing,
tenants’ legal rights, and resources (California Department of Public Health, 2007). This material
is available in English and Spanish and is equivalent to the fotonovela’s health messages on
SHS. It does not, however, address THS. For this reason, the research team developed a separate
fact sheet as a supplement to this tool with the missing health messages. This study was
approved by the university’s institutional review board.

56

Sampling and Data Collection
This is a randomized controlled trial with a pre/post prospective design. This sample is
drawn from a survey of Hispanic tenants of multi-unit housing (MUH) in the Los Angeles area in
2014 (Delgado Rendon et al., 2015). Participants were Hispanic adults living in randomly
selected MUH units in eastern metro Los Angeles. They were identified using a four-step
process described previously (Delgado-Rendon et al., 2017). Up to a maximum of 5 adult tenants
per building were allowed to enroll in the study. A total of 1,272 residents were invited to
participate out of which 449 did not meet the eligibility criteria (adult, Hispanic/Latin American,
living in the unit), of the remaining 823 people that were eligible, 402 consented to participate at
baseline. Participants in each building were randomly assigned to the treatment group (exposure
to the fotonovela, n=115), comparison group (pamphlet, n= 108), or control group (no material,
n=114) based on their residence (total number at post time = 337).
Measures
Demographic characteristics included self-reported age, gender, country of birth,
ethnicity, total years of formal education in the U.S. and country of origin, language preference
for completing the surveys, and annual household income. Household characteristics included
number of residents in the unit. Level of education from country of origin and from the U.S.
were self-reported. These characteristics were included in the study to account for potential
confounders of literacy.
Literacy assessment tools tend to be too long for clinical settings, developed in English,
and overwhelming for illiterate individuals (Morris, Maclean, Chew, & Littenberg, 2006). In this
study, we used a simple single item measure validated to evaluate health literacy and measured
the literacy levels of our materials of 8
th
grade school reading level in both languages using the

57

SMOG test (Pechero Bishop et al., 2016). Health literacy was assessed using a single item
literacy screener (SILS) in English and Spanish (Morris et al., 2006). While there are several
tests of the health literacy capacity of audiences (Aguirre et al., 2005; Chinn & McCarthy, 2013;
Dumenci et al., 2013; Lee, Bender, Ruiz, & Cho, 2006; P. W. Murphy & et al., 1993). the Single
Item Literacy Screener (SILS) can correctly identify up to 81% of the population with inadequate
or marginal health literacy (Chew et al., 2008; Chew et al., 2004; Morris et al., 2006). The SILS
question “How confident are you filling out medical forms?” was recently validated in English
and Spanish that allows practitioners to identify patients with functional literacy challenges
quickly (Sarkar et al., 2011). Possible answers were rated from no confidence at all to extremely
well (0 to 4 respectively). Following the validation studies of the SILS, a score of 2 or less was
considered inadequate health literacy (low health literacy) and 3 to 4 were considered adequate
(high health literacy) (Chew et al., 2008; Chew et al., 2004; Morris et al., 2006). Literacy was
measured using level of education from the U.S. or another country as a proxy in order to
compare its relationship with health literacy.
Observations collected at baseline were labeled T1 and those collected at follow up were
labeled T2. Outcome variables included scales for personal home smoking policy and
enforcement (used single items), support for a smoke-free building policy (T2 a=0.81), exposure
to SHS, SHMS, and THS (used single items), knowledge about SHS, SHMS, and THS (T1 a=
0.39, T2 a=0.52), protective attitudes against SHS/THS (T1 a= 0.45, T2 a=0.30), favoring
smoking bans (T2 a=0.81), perceived self-efficacy to protect against smoke exposure (T1 a=
0.73, T2 a=0.80), perceived collective efficacy to protect against exposure (T2 a=0.91), and
behaviors to protect themselves from exposure have been described in a previous publication (T2
a=0.70 (Delgado-Rendon et al., 2017). The knowledge and attitude scales contained items which

58

were not originally designed to converge, in this case alpha scores not the only way to assess
reliability. The subcategories of each scale had higher alpha scores vouching for the content of
each item.
Statistical Analysis
Data were cleaned and cleared of errors in Stata. Analyses were conducted with Stata
13.0 ® (StataCorp, 2013). Group size was calculated prior to collecting the data to achieve
enough power for the analysis. Stata 13.0 automatically deleted missing observations from the
calculations. The responses to the Likert-type questions were summed up to yield cumulative
scores for scales and subscales. For the regression analysis, independent variables were the
treatment received (fotonovela, pamphlet, no material), health literacy levels in English and
Spanish, and the interaction of treatment type with EHL/SHL (Treatment condition x EHL or
SHL). Demographic characteristics of the participants who completed the post-survey were
computed using descriptive statistics (Table 1). Age and sex/gender characteristics were
covariates. Variables included were EHL (T1), SHL (T1), education in Spanish, education in
English, total number of years of education, knowledge (T1 and T2), attitudes (T1 and T2), self-
efficacy (T1 and T2), collective efficacy (T2), tendency to favor smoking bans (T2), and
protective behaviors (T2). Analyses were also conducted between key demographic, theory
constructs that guided the creation of the fotonovela, and outcome variables to assess for
confounding and interaction effects. Differences among the three treatment groups were
evaluated using Scheffe pairwise comparison and Anova tests were used to assess the overall
intervention.
Hypothesis 1. Pearson correlations were computed to assess the relationships between
participants’ characteristics, EHL, SHL, education, and outcome variables: Knowledge (T2),

59

self-efficacy (T2), protective attitudes (T2), favoring smoking bans (T2), collective efficacy
(T2), and protective behavior (T2). Anova analyses were conducted comparing the 3 treatment
groups (Fotonovela, Comparison Pamphlet, and Control). Moderation analyses were conducted
evaluating the role of EHL or SHL as the moderator on group placement and key outcomes.
Regression analyses were conducted on the outcomes including the treatment as an independent
variable and health literacy as a covariate, then the same regression analyses were repeated with
an interaction term of intervention group X health literacy. If the interaction term has a
statistically significant coefficient, it is said that health literacy has moderation effects on the
relationship between study group placement (fotonovela, pamphlet, or nothing) and the
outcomes.

Hypothesis 2. Groups were stratified by preferred language (English or Spanish) and
moderation analyses were carried out to evaluate for potential interaction of EHL/SHL on group
placement and key outcomes and between baseline and follow up outcome variables (Figure 60).
Figure 12. Conceptual framework for study 2.

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Results
Sample characteristics
The total sample of participants that completed the post-survey was 337 Hispanic/Latin
American apartment residents (fotonovela group = 115, brochure = 108, control = 114). The final
sample was made up of 252 (75%) women, 208 (62%) preferred to complete the survey in
Spanish, 104 (31%) were born in the U.S., and 218 (65%) were of Mexican ethnicity (see Table
7). The remaining 35% (n = 118) reported their ethnicity as: Caribbean (4), Central American
(62), South American (6), Portuguese (1), Filipino (1), mixed various Hispanic origins (4), and
unspecified Hispanic/Latin American (40). When asked about their race, the majority did not
provide a specific race (241, 71.5%); of those who did, the highest reported category was
mestizo/a having Native American (66/96 = 69%).
The median total years of formal education was 12 years with 37% having less than a
high school/GED degree. The median annual household income was $20,000 to $29,000 dollars.
Figure 13. Conceptual framework for hypothesis 2 of study 2.

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On average there were 2.5 adults and 1.3 children living in the homes. The average level of
health literacy in English (EHL) was lower than the Spanish level (SHL), 2.0 versus 2.7
respectively (0=not at all to 4=Extremely well).
At follow up data collection time, 22% of the participants reported living with a smoker
(any type of tobacco product), only 3.6% allowed smoking inside their homes, 69% smelled SHS
inside their homes, 72% smelled SHS in their buildings, 46% smelled secondhand marijuana
smoke (SHMS) inside their homes, and 49% smell SHMS in their building. Ninety four percent
of the participants reported that their buildings had rules against tobacco smoke, 30% had rules
against e-cigarette smoking, and 55% had rules against marijuana smoke (not specific for
medicinal or recreational marijuana).

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Variables Fotonovela
N = 115
Brochure
N = 108
Control
N = 114
Overall
N = 337
Demographics
Age in years (Mean ± SD, min 17 – max 92) 39.0 ± 15.0 38.7 ± 14.8 40.3 ± 15.2 39.3 ± 15.0
% Female 77.4% 71.3% 75.4% 74.8%
% Spanish language 63.5% 64.8% 57.0% 61.7%
% Born in the U.S. 28.7% 25.0% 38.6% 31.0%
% Mexican Ethnicity 61.0% 63.0% 70.2% 64.7%
Years of education (Mean ± SD) 10.3 ± 3.9 10.6 ± 3.6 11.33 ± 3.3 10.8 ± 3.6
% < High school or GED
3
(n=221) 26.5% 38.8% 30.7% 37.4%
Annual household income (Median)
1
$20k - $29k $10k -$19k* $20k -$29k* $20 k - $29 k
Adults at home (Mean ± SD) 2.4 ± 1.0 2.6 ± 1.0 2.4 ± 0.8 2.5 ± 0.9
Children at home (Mean ± SD) 1.3 ± 1.2 1.5 ± 1.3 1.2 ± 1.1 1.3 ± 1.2
Health literacy in English (Mean ± SD) 1.9 ± 1.6 1.8 ± 1.5 2.3 ± 1.6 2.0 ± 1.6
Health literacy in Spanish (Mean ± SD) 2.7 ± 1.4 2.6 ± 1.4 2.7 ± 1.4 2.7 ± 1.4
Characteristics related to smoking
% Live with a smoker 18.3% 23.2% 23.7% 21.7%
% Allow smoking at home 3.5% 2.8% 4.4% 3.6%
% Smell SHS at home 74.0% 73.1% 58.8% 68.5%
% Smell SHS in building 74.0% 76.0% 65.8% 71.5%
% Smell marijuana at home 54.8%* 48.6% 36.0%* 46.4%
% Smell marijuana in building 50.4% 48.6% 47.4% 48.8%
Any rules against smoking
2
(%) 40.0% 44.4% 30.1% 38.1%
% Rules against tobacco smoke (n=128) 95.7% 95.8% 88.2% 93.75%
% Rules against e-cig smoke (n=128) 23.9% 37.5% 26.5% 29.7%
% Rules against marijuana smoke (n=128) 62.2% 45.8% 52.9% 54.7%
% Favors any rule at baseline (n=334) 88.6% 86.0% 84.2% 86.2%
% Favors a tobacco rule at post (n=336) 87.0% 90.7% 88.5% 88.7%
% Favors a e-cig rule at post (n=329) 77.2% 78.1% 73.6% 76.3%
% Favors a marijuana rule at post (n=335) 85.1% 87.0% 85.0% 85.7%

Table 7. Demographic characteristics of the sample population by treatment condition (N=337)

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Also, 89% favored rules against tobacco in their buildings, 76% favored rules against e-
cigarette smoking, and 86% favored rules against marijuana smoke. Specific percentages of the
information for each treatment condition is listed in Table 7. Differences among the groups’
characteristics and outcome measures were assessed using the Scheffe comparison test. Overall,
there no significant differences across the three intervention groups, indicating that the random
assignment was successful.
Assessing the data on their use of the material provided (only fotonovela and brochure
study groups without the control) showed that 24% (n = 223) of the participants reported having
read the entire material, and 73% reported having read some or all of the material. Out of the
participants who read some or all of the material the majority (81%, n = 174) were able to
identify one or more of the main messages from a list of topics, including a few distractor topics
Community recirculation (passing the material along) occurred among 46.2% (n = 223)
including people who gave the material to another person or left it in a place where that person
could find it. Sixty-three percent of the readers said they spoke with another person about the
information in the booklets.
Hypothesis 1
In this analysis, we test the effects of the fotonovela and pamphlet interventions on key
outcomes and whether the outcomes are moderated by levels of English health literacy and
Spanish health literacy among all participants regardless of preferred language.
When comparing the study sample by levels of health literacy using t-tests, there were
several differences. The group high in SHL tended to be older (p=0.04), more likely to speak
Spanish, less likely to have been born in the U.S. (p<0.00), had less years of total education
(p=0.03), more likely to have gone to school outside of the U.S., (p<0.00), and have more

64

children living in the house (p<0.00). Interestingly, Hispanics with a high level of literacy in
Spanish reported a higher prevalence of SHMS in the building (p=0.01) and were more likely to
favor bans on tobacco smoke, e-cigarette smoking, and marijuana smoking (p<0.00). Individuals
with higher SHL had a higher baseline of knowledge about SHS and THS than low SHL
individuals.
Separating the participants by levels of health literacy in English yielded similar
differences between the low and high health literacy groups. Those with high EHL were younger
and less likely to prefer to use Spanish (p<0.00 and p<0.00). This is not surprising given that
English is the standard language in California. High health literate individuals had more years of
total education (p<0.00). Participants with low EHL reported lower median household incomes
than those with higher EHL (p<0.00). Hispanics with high EHL were more likely to live with a
smoker and allow smoking at home (p<0.00 and p=0.01). Similar to the outcomes related to
people with low SHL, people with high EHL were less likely to favor any types of smoking bans
in their building (p<0.00). Participants with high EHL reported a better self-efficacy (T1 and T2)
to protect themselves against SHS/THS than participants with high SHL (p£0.05). People with
low level of English health literacy were statistically more likely to report higher collective
efficacy (p£0.05).
Years of education by country of education and overall total years of formal education
were highly collinear with the single item health literacy screeners (SILS) and thus the three
education variables were excluded from subsequent analyses. Health literacy in Spanish was
moderately negatively correlated with health literacy in English (r = -0.19, p £ 0.05). Protective
attitudes and self-efficacy about smoke exposure were somewhat correlated with English literacy
(p £ 0.05).

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Table 8. Participant characteristics by level of Spanish health literacy level.

66

Table 9. Participant characteristics by level of English health literacy.

67

a
Knowledge, attitudes, self-efficacy, collective efficacy, favoring bans, and protective behaviors at post-
time (T2). Collective efficacy, favoring smoking bans, and protective behaviors were measured only at
post-time (T2). * A significant effect was found in these correlations (p£0.05).

There was no correlation between protective attitudes, self-efficacy, and SHL. Higher
SHL was statistically correlated with more likelihood to favor bans in the building (r = 0.27, p £
0.05). Age was correlated with more likelihood of moving out of a building rather than
confronting the problem of SHS with neighbors and landlords (r = -0.16, p £ 0.05).
Moderation analysis did not reveal any interaction effects between the study group
placement (control – no educational material, comparison – written pamphlet, and intervention –
fotonovela) and health literacy in English or Spanish in the prediction of changes in knowledge
and protective attitudes. The null hypothesis 1 of no moderation cannot be rejected.
Hypothesis 2
Before the second analysis, we separated the groups by preferred language (Spanish =
208, English = 129), then tested whether the effects of the fotonovela and pamphlet interventions
on key outcomes were moderated by levels on EHL among English dominant speakers and SHL
among Spanish dominant speakers.
Table 10. Intercorrelations among study variables and health literacy items.

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First, we tested whether there were improvements of the key outcomes from baseline
(T1) to follow up (T2) for any of the educational groups and found no improvements in
knowledge and protective attitudes. Changes in protective behaviors could not be assessed
because they were only tested at follow up (T2). There was a statistically significant difference
between protective behaviors (T2) reported at follow up for the fotonovela and pamphlet groups
compared with the control group (p £ 0.05).
To further explore the effect of health literacy, we stratified by preferred language and
then analyzed the association of educational material group on key outcomes, knowledge,
protective attitudes, favoring bans, protective behaviors, and found an interaction effect among
Spanish speakers in the brochure group between level of Spanish health literacy and knowledge
of SHS/THS at follow up (Spanish speakers only n = 71, for pamphlet x SHL, b = 1.95, p £
0.01). In other words, those with low Spanish health literacy who were exposed to the pamphlet
were more likely to have lower levels of knowledge about SHS compared to those with higher
health literacy. This finding points to possible literacy barriers in Spanish for Hispanics with
low health literacy in Spanish when reading a heavy text material.
Discussion
The findings show that overall the pamphlet and fotonovela had similar results regardless
of the level of health literacy of the participants. The current study did not find interaction effects
of health literacy in either language and group placement six months after exposure to the
educational materials for any of the outcomes (knowledge, attitudes, self-efficacy and collective
efficacy related to protection against smoke, favoring smoking bans, and protective behaviors
related to smoke exposure). It is possible that improvement in outcomes were not observed due
to the six-month lapse in collecting the post measurements after exposure. The life span of

69

knowledge gains wanes just seven days to four months after communication campaigns
(Finseraas, Jakobsson, & Svensson, 2017; Mazor & Billings-Gagliardi, 2003). Future
educational plans should be timed with specific events of importance such as when a new tenant
signs the rental agreement.
Although total years of education and EHL/SHL were statistically correlated, this study
shows that total years of education should not be used as a proxy for EHL/SHL as language of
education is a better indicator of health literacy. The direction of the correlation between total
years of education and EHL/SHL reversed when comparing EHL/SHL with years of education in
Spanish and the variance was larger (See Table 10). For example, total years of education was
negatively correlated with health literacy in Spanish, but this direction reversed when people
were educated in Spanish speaking schools. Health literacy entails not only being able to
understand, but also use the health information imparted to make the good health decisions,
“making informed health choices” being a difference between education and health literacy.
Participants with high EHL reported a better self-efficacy (T1 and T2) to protect
themselves against SHS/THS than participants with high SHL (p£0.05), supporting previous
studies that show European – Americans have higher internal locus of control than Hispanics
(Derald Wing Sue & Sue, 2008; Shen, Condit, & Wright, 2009). People with low level of
English health literacy were statistically more likely to report higher collective efficacy (p£0.05),
reflecting a measure of interdependence among participants with lower EHL (Azara L Santiago-
Rivera, Arrendondo, & Gallardo-Cooper, 2002). Aligning with Anglo and Hispanic cultural
orientations, English speakers had higher self-efficacy, and Spanish speakers had higher
collective efficacy signaling different paths that could be used to disseminate the information and
enforce rules at the building level. For example, in future interventions for people with higher

70

collective efficacy, it would be advised to assure that at least 1 person in the household reads the
entire booklet, perhaps during a neighbors meeting followed by a discussion.
Participants with low EHL and high SHL were less likely to live with a smoker and less
likely to allow smoking at home, and they were more likely to favor smoking bans of tobacco, e-
cigarettes, and marijuana. Participants with low EHL also reported higher prevalence of SHMS
in the building. It is possible that Hispanics may favor city laws and managers enforcing the
rules due to having high external locus of control and to overcome the cultural differences of
respect for the smokers (Delgado Rendon et al., 2015; Derald Wing Sue & Sue, 2008). Based on
the participants’ preferences, future efforts should explore the feasibility of smoking policies and
enforcement of smoking areas (Baezconde-Garbanati et al., 2011).
There was a significant interaction effect of knowledge change moderated by SHL such
that participants who preferred to complete the survey in Spanish were able to make greater
improvements in knowledge after reading the pamphlet. This result signals that for Spanish
speaking Hispanics who have low SHL, reading heavy text materials in Spanish (pamphlet) may
be a barrier that will not improve their knowledge. In such cases, the graphic novel should be
considered for future health communication campaigns. This finding suggests that levels of
health literacy do not interact with reading graphic novels with low literacy text, and therefore
graphic novels could overcome literacy barriers; however, further clarification is needed with
follow up data collected soon after exposure to the material to determine if this result
shows up soon after the intervention but fades after 6 months.
Technology-based communication media, social media and the internet, form the frontier
of the health literacy research; as such, they could be used as a delivery mechanism to
disseminate the graphic novels.

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Limitations
This paper describes the inclusion of a number of Central Americans; however, their
numbers were not enough to disaggregate the data. Although people of Mexican background
make up the majority of Hispanics in California, research suggests that there are differences in
adoption of smoking rules between various groups, whereas Hispanics from the Caribbean and
Central America may have lower rates of smoking bans at home due to higher smoking rates
(O'Hegarty, Pederson, Asman, Thorne, & Caraballo, 2013). In the future, it is important to
analyze unique characteristics regarding smoking bans that are specific to these regional groups
to lay a foundation for more tailored interventions.
The post – survey data was collected 6 months after exposure to the educational
materials. Part of the outcomes rely on the participants’ recollection of the information imparted
and this recall may have lessened over time. Nonetheless, we expected to gain insight into the
mechanisms of how health literacy can moderate changes in tobacco education. Univariate
analysis provides insights of the specific effects over time of the fotonovela. The study design
lends itself to an internal validity weakness; the baseline survey items alert the participant of the
messages to be imparted and may implicitly change their focus while reading the intervention
and comparison materials. It is unlikely that the participants’ levels of health literacy changed
significantly during the six months between the baseline and post measures data collection
points.
Conclusions
The research literature before mentioned tells us that participants with low levels of
health literacy warrant tailored interventions, further tailored if they are Hispanics who are fluent
Spanish speakers as opposed to those who are more fluent in English. Our results partly support

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these assumptions. The only significant interaction effect signaled that among Spanish speaking
Hispanics, knowledge after reading the brochures with text heavy content is moderated by SHL
such that comprehension of the information is less likely among those with low health literacy in
Spanish. In our study, text heavy material required that the Spanish speaking reader has a higher
degree of health literacy to process their content compared to the fotonovela. This result suggests
that fotonovelas can overcome healthy literacy limitations to effectively communicate health
messages for bilingual individuals and Spanish speakers, however further research is needed to
confirm the immediate effects of reading the materials among low literacy individuals.
Implications and Future Directions
The results warrant future research to find if health literacy moderates learning from text
heavy materials and if language fluency among bilinguals affects those results. We found varied
levels of support for smoking policies in the homes and buildings. Socioecological interventions
that incorporate smoking policies and enforcement at the community level would be preferred by
the Spanish speakers and should be included in the research agenda. Important demographic
disparities exist between the participants with low versus high EHL/SHL. Age, language
preference, years of education, and number of children at home may be useful to design
interventions that complement educational campaigns and policies and should be further
investigated in future research endeavors.

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Chapter 4. Overall Discussion & Implications
Summary of Findings
This dissertation’s research is pioneering in its methodology and theoretical work. Data
was collected from Hispanic residents of apartment buildings in Los Angeles County to study the
efficacy of two educational materials in increasing participants’ knowledge, protective attitudes,
and behaviors against SHS, SHMS, and THS. This dissertation research advanced our
understanding of the roles of health literacy and social cognitive theory on the efficacy of a
pamphlet and fotonovela for the prevention of exposure to SHS.
The questions posed in this dissertation have not yet been addressed in the current
literature. The first study addresses the questions: What are the associations among health
literacy, health behavior outcomes, and neighborhood characteristics? What is the role of health
literacy in the acquisition and maintenance of knowledge about the risks of SHS? The second
study addresses the questions: How does self-efficacy affect people’s decision to take action to
protect themselves against SHS? What is the mediating role of social cognitive theory constructs
in the effect of the educational materials?
The first study contributed to our understanding of the connection among key
components of health education campaigns: the reading level of educational materials, narrative
format versus text format, the audience’s level of health literacy, and language of literacy.
Previous research had not included measures for these components, nor did it report these
factors’ association with knowledge, attitude, and behavior outcomes of educational campaigns.
The study assessed the long-term effects of a fotonovela among a group of Hispanics with
various levels of baseline health literacy. This study also afforded us the opportunity to examine

74

the moderating effects of reading comprehension of Hispanics at risk of smoke pollution at
home.
Individuals with high Spanish health literacy (SHL) were more likely to favor all types of
smoking bans and report higher collective efficacy to protect themselves and their families at
follow up. Moderation analysis did not reveal any interaction effects between the type of
educational materials exposure and SHL or English health literacy (EHL) on knowledge,
attitudes, and behavior. After stratifying by preferred language, moderation analysis showed that
for Spanish speakers SHL interacted with the association between reading the pamphlet and
knowledge about SHS. The first study found interaction effects of Spanish health literacy on the
association between type of material (pamphlet) and knowledge for Spanish speakers, partly
supporting our initial hypothesis. Participants with high SHL reported higher collective efficacy
to deal with SHS exposure. Further research is needed to clarify the immediate effects of health
literacy for Hispanics with low health literacy in either language.
The second study illustrated the advantages of using certain social cognitive constructs in
the design and implementation of mass public health campaigns. Protective behaviors related to
SHS at follow up were better for the brochure and fotonovela intervention groups than for the
control. For the fotonovela group participants, baseline perceived self-efficacy and collective
efficacy at follow up were associated with protective attitudes about talking with neighbors, and
collective efficacy was associated with protective behaviors at follow up. Social cohesion and
communication with neighbors correlated strongly with self-efficacy, collective efficacy, and
protective behaviors. Mediation analysis of the social cognitive theory constructs revealed
potential psychosocial paths from self-efficacy at baseline to protective behaviors against
exposure to SHS at follow up via collective efficacy.

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Theoretical Implications
Findings from the second study support the research on the importance of social
cognitive theory in health education. A potential model of the causal structure from self-efficacy
to protective behaviors of SHS was proposed. The first part of the model involved the association
between the participants’ baseline level of self-efficacy and intentions to engage in protective
behaviors at follow up was mediated by having positive expectations of initiating conversations
with neighbors and managers about SHS. The second part of the model concluded that the
association between intentions and protective behaviors was mediated by the participants’
perception of collective efficacy of their neighborhood. These findings support the initial causal
model proposed by Albert Bandura.
The findings point to mediating effects, but causation cannot be concluded. Future
research is needed with a larger sample and theory data collected at baseline to test the model in
its entirety using other statistical methods such as structural equation modeling. Neighborhood
characteristics of social cohesion and frequency of communication with neighbors and managers
are important factors when designing interventions to decrease SHS pollution in shared and open
spaces and should be incorporated. More intensive behavioral interventions that complement
educational materials at the environmental and policy levels are needed to make lasting changes.
Methodological Implications
These studies are groundbreaking because no other study has tested an educational
graphic novel’s theoretical mechanisms using a randomized three group cohort. The apartment
sites encompassed properties all over Los Angeles County representing the Hispanic population.
This work informs the foundation for future research to better understand communication
strategies and mechanisms that can reduce tobacco related disease burden in low health literacy

76

Hispanic populations. The studies included in this dissertation provide supportive evidence for
the moderating role of health literacy among a bilingual audience as well as the mediating role of
collective efficacy in the two intervention groups’ yielding better protective behaviors than the
control group. These findings are limited in that most of the theoretical data was collected at
follow up, thus rendering us unable to assert causation of theoretical constructs,
sociodemographic characteristics of the participants, neighborhood attributes, and outcomes. The
study showed that both the text heavy and graphic novels yielded similar results at persuading
multi-unit housing Hispanic residents to change their attitudes and behaviors towards prevention
of exposure to SHS, SMHS, and THS., therefore both can be used in future communication
campaigns. Dissemination of the materials could be targeted to people according to the
preference of different groups. The analysis filled a gap because no other randomized controlled
study has been done with multi-unit housing Hispanic dwellers testing Social Cognitive Theory
and advanced our understanding of the effects of literacy levels of the materials and study
participants on reducing tobacco related diseases. These findings provide information for
addressing the racial and ethnic disparities in exposure to tobacco smoke.
Implications for future research
The 1st study demonstrated the advantages of using certain social cognitive constructs in
the design and implementation of mass public health campaigns. It is important to explore the
limitations of the two studies in order to propose clear suggestions for researchers in the field.
This work informs the foundation for future research applications to better understand
communication strategies and mechanisms that can reduce tobacco related disease burden in low
health literacy Hispanic populations. The 1
st
study added to the body of research on social
cognitive theory given that self-efficacy has been associated with protective factors of SHS. The

77

study proposed advanced this gap in knowledge by shining light on the long-term effects of such
interventions on prevention of SHS. Most educational studies assess immediate knowledge
gains, this study assesses knowledge retained after 6 months of being exposed to the materials as
well as other outcomes of relevance. A potential model of the causal structure from self-efficacy
to protective behaviors of SHS is proposed. Neighborhood characteristics of social cohesion and
frequency of communication with neighbors and manager are important factors when designing
interventions to decrease SHS pollution in shared and open spaces. Health professionals and
policy makers should consider including the components of this model for future plans of
addressing exposure to tobacco, marijuana, and e-cigarette smoke in shared living spaces. Future
research is needed with a larger sample and theory data collected at baseline to test the model in
its entirety using other statistical methods such as structural equation modeling.
The 2
nd
study extended our understanding of very important factors of educational
interventions: the connection between the reading level of materials and health literacy of the
participants. It is our understanding that, these factors while commonly brought up in health
behavior research had not actually been evaluated, prior to this research. The study assessed the
long-term effects of a fotonovela among a group of Hispanics with various levels of
acculturation to European-American culture and baseline levels of health literacy. This study
afforded us the opportunity to examine the moderating effects of reading comprehension of
Hispanics at risk of smoke pollution at home.
Implications for practice settings
The health literacy investigation helps practitioners identify bilingual individuals with
low health literacy using the SILS and/or years of education in their preferred language.

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Practitioners could have both types of materials available, text heavy and graphic story, and use
each according to the audience preferred method of learning.
We found varied levels of support for smoking policies in the homes and buildings.
Socioecological interventions that incorporate smoking policies and enforcement at the
community level would be preferred by the Spanish speakers and should be included in the
research agenda. Important demographic disparities exist between the participants with low
versus high EHL/SHL. Age, language preference, years of education, and number of children at
home may be useful to design interventions that complement educational campaigns and policies
and should be further investigated in future research endeavors.

79

References
Aguirre, A. C., Ebrahim, N., & Shea, J. A. (2005). Performance of the English and Spanish S-
TOFHLA among publicly insured Medicaid and Medicare patients. Patient Education
and Counseling, 56(3), 332-339. doi:10.1016/j.pec.2004.03.007
Alcalay, R., Alvarado, M., Balcazar, H., Newman, E., & Huerta, E. (1999). Salud Para Su
Corazón: A Community-Based Latino Cardiovascular Disease Prevention and Outreach
Model. Journal of Community Health, 24(5), 359-379. doi:10.1023/A:1018734303968
American Non-Smokers’s Rights Foundation. (2019). States and Municipalities with Laws
Regulating Use of Electronic Cigarettes. Retrieved from https://no-smoke.org/wp-
content/uploads/pdf/ecigslaws.pdf
Arborelius, E., Hallberg, A. C., & Håkansson, A. (2000). How to prevent exposure to tobacco
smoke among small children: a literature review. Acta Pædiatrica, 89, 65-70.
doi:10.1111/j.1651-2227.2000.tb03098.x
Azara L Santiago-Rivera, Arrendondo, P., & Gallardo-Cooper, M. (2002). Counseling Latinos
and La Familia: A practical guide (S. Publications Ed. 1st ed.). Thousand Oaks, CA:
Sage Publications.
Baezconde-Garbanati, L., Weich-Reushe, K., Espinoza, L., Portugal, C., Barahona, R.,
Garbanati, J...Unger, J. B. (2011). Secondhand Smoke Exposure Among
Hispanics/Latinos Living in Multiunit Housing: Exploring Barriers to New Policies. The
Science of Health Promotion, 25(5), Supplement 82 - 90. doi:10.4278/ajhp.100628-
QUAL-219
Bandura, A. (1977). Social Learning Theory. Englewood Cliffs, NJ: Prentice Hall.
Bandura, A. (1994). Self-efficacy. Encyclopedia of Human Behavior, 4, 71-81.
Bandura, A. (1995). Self-Efficacy in Changing Societies (A. Bandura Ed. 1st edition ed.). New
York, New York: Cambridge University Press.
Bandura, A. (1997). Self-efficacy : the exercise of control. New York: W.H. Freeman.
Bandura, A. (1998). Health promotion from the perspective of social cognitive theory.
Psychology & Health, 13(4), 623-649. doi:10.1080/08870449808407422
Baranowski, T., Baranowski, J., Cullen, K. W., Demoor, C., Rittenberry, L., Hebert, D., & Jones,
L. (2002). 5 a Day Achievement Badge for African-American Boy Scouts: Pilot Outcome
Results. Preventive Medicine, 34(3), 353-363. doi:10.1006/pmed.2001.0989
Baron, M., Lopez, J., Molina, G., Lopez de Dennis, G., Zendejas, E., Sharma, N., and Powers,
M. (2012). Rosa Out of Control.
Baron, R., & Kenny, D. (1986). The moderator-mediator variable distinction in social
psychological research: conceptual, strategic, and statistical considerations. Journal of
Personality and Social Psychology, 51(1986), 1173-1182.
Becerra, B. J., Arias, D., & Becerra, M. B. (2017). Low Health Literacy among Immigrant
Hispanics. J Racial Ethn Health Disparities, 4(3), 480-483. doi:10.1007/s40615-016-
0249-5
Blaakman, S. W., Borrelli, B., Wiesenthal, E. N., Fagnano, M., Tremblay, P. J., Stevens, T. P., &
Halterman, J. S. (2015). Secondhand Smoke Exposure Reduction After NICU Discharge:
Results of a Randomized Trial. Academic pediatrics., 15(6), 605-612.
doi:10.1016/j.acap.2015.05.001

80

Brannon Br Fau - Wagstaff, D. A., & Wagstaff, D. A. (1983) Skin cancer/melanoma public and
professional education in Hawaii: an integrated approach to technology transfer. (0361-
7742 (Print)).
Branscum, P. W. (2011). Designing and evaluating an after-school social cognitive theory based
comic book intervention for the prevention of childhood obesity among elementary aged
school children. (Doctor of Philosophy Dissertation), University of Cincinnati, Ohio.
Bruner, J. (1986). Actual minds, possible worlds. Cambridge, MA: Harvard University Press.
Bureau, U. S. C. (2017). Census Quick Facts Los Angeles County, California. Census Bureau
Retrieved from
https://www.census.gov/quickfacts/fact/table/losangelescountycalifornia#viewtop
Bureau, U. S. C. (2019). Quitck Facts United States. Retrieved from
https://www.census.gov/quickfacts/fact/table/US/RHI725218
Butler Flora, C. (1980). Fotonovelas: Message Creation and Reception. Journal of Popular
Culture, 14(3), 524-534.
Cabassa, L. J., Contreras, S., Aragon, R., Molina, G. B., & Baron, M. (2011). Focus group
evaluation of "Secret Feelings": a depression fotonovela for Latinos with limited English
proficiency. Health Promotion Practice, 12(6), 840-847.
doi:10.1177/1524839911399430
Cabassa, L. J., Molina, G. B., & Baron, M. (2012). Depression fotonovela: development of a
depression literacy tool for Latinos with limited English proficiency. Health Promot
Pract, 13(6), 747-754. doi:10.1177/1524839910367578
Cabrera, D. M., Morisky, D. E., & Chin, S. (2002). Development of a tuberculosis education
booklet for Latino immigrant patients. Patient Education and Counseling, 46(2), 117-
124. doi:10.1016/S0738-3991(01)00156-2
California Department of Public Health. (2007). Secondhand smoke and apartments, condos and
townhouses (Education Catalogue).
Carnaghi, A., Cadinu, M., Castelli, L., Kiesner, J., & Bragantini, C. (2007). The best way to tell
you to use a condom: The interplay between message format and individuals’ level of
need for cognition. AIDS Care, 19(3), 432-440. doi:10.1080/09540120600582013
Chan, A., Brown, B., Sepulveda, E., & Teran-Clayton, L. (2015). Evaluation of fotonovela to
increase human papillomavirus vaccine knowledge, attitudes, and intentions in a low-
income Hispanic community. BMC research notes, 8(1), 615. doi:10.1186/s13104-015-
1609-7
Chen & Cheng Sim (1985). The development of culture-specific health education packages to
increase case-finding of leprosy in Sarawak. (0125-1562).
Chew, L., Griffin, J., Partin, M., Noorbaloochi, S., Grill, J., Snyder, A., . . . VanRyn, M. (2008).
Validation of Screening Questions for Limited Health Literacy in a Large VA Outpatient
Population. Journal of General Internal Medicine, 23(5), 561-566. doi:10.1007/s11606-
008-0520-5
Chew, L. D., Bradley, K. A., & Boyko, E. J. (2004). Brief questions to identify patients with
inadequate health literacy. Family medicine, 36(8), 588.
Chinn, D., & McCarthy, C. (2013). All Aspects of Health Literacy Scale (AAHLS): Developing
a tool to measure functional, communicative and critical health literacy in primary
healthcare settings.(Report). Patient Education and Counseling, 90(2), 247.

81

Cilluffo, A., Geiger, A. W., & Fry, R. (2017). More U.S. households are renting than at any point
in 50 years. FacTank News in the Numbers. Retrieved from
https://www.pewresearch.org/fact-tank/2017/07/19/more-u-s-households-are-renting-
than-at-any-point-in-50-years/
Contreras, A., Garcia-Alonso, R., Echenique, M., & Daye-Contreras, F. (1999). The SOL
formulas for converting SMOG readability scores between health education materials
written in Spanish, English, and French. J Health Commun, 4(1), 21-29.
doi:10.1080/108107399127066
Cook, N. J., Hollar, L., Chavez, S., Quinn, D. L., Phillips, T., DeLucca, M., & Corrales, L.
(2014). Support for smoke-free multi-unit housing policies among racially and ethnically
diverse, low-income seniors in South Florida. J Cross Cult Gerontol, 29(4), 405-415.
doi:10.1007/s10823-014-9247-4
Cooper Jr., M., Michael, Blucker, P., Ryan, Thompson, P., David, Griffeth, B., Elaine, Grassi,
B., Michael, Damron, B., Kelsey, . . . Dunlap, M., Marianne. (2018). Health Literacy
Estimation of English and Spanish Language Caregivers. Health Literacy Research and
Practice, 2(2), e107-e114. doi:10.3928/24748307-20180503-02
Cullen, K. W., Baranowski T Fau - Baranowski, J., Baranowski J Fau - Warnecke, C., Warnecke
C Fau - de Moor, C., de Moor C Fau - Nwachokor, A., Nwachokor A Fau - Hajek, R. A.,
Jones, L. A. (1998) "5 A Day" achievement badge for urban boy scouts: formative
evaluation results. (0885-8195 (Print)).
De Varennes, F. (2001). Language Rights as an Integral Part of Human Rights. International
Journal on Multicultural Societies, 3(1), 15-25. doi:UNESCO
de Vries H, & E., B. (1994). Self-eficacy as an important determinant of quitting among pregnant
women who smoke: The 0-pattern. Prev Med, 23(2), 167-174.
Delgado Rendon, A., Cruz, T., Baezconde - Garbanati, L., Soto, C., & Unger, J. B. (2019).
Managers’ Practices of Tobacco and Marijuana Smoking Policies in Hispanic Occupied
Multi-Unit Housing. Journal of Health Equity. 3 (2): 304-311.
Delgado Rendon, A., Unger, J. B., Cruz, T., Soto, D. W., & Baezconde-Garbanati, L. (2015).
Perceptions of Secondhand and Thirdhand Smoke Among Hispanic Residents of
Multiunit Housing. J Immigr Minor Health. doi:10.1007/s10903-015-0309-7
Delgado-Rendon, A., Cruz, T. B., Soto, D., Baezconde-Garbanati, L., & Unger, J. B. (2017).
Second and Thirdhand Smoke Exposure, Attitudes and Protective Practices: Results from
a Survey of Hispanic Residents in Multi-unit Housing. J Immigr Minor Health, 19(5),
1148-1155. doi:10.1007/s10903-016-0540-x
Derald Wing Sue, & Sue, D. (2008). Counseling the Culturally Diverse: Theory and Practice
(5th Edition ed.). Hoboken, New Jersey: John Wiley & Sons.
Díez-Izquierdo, A., Cassanello-Peñarroya, P., Lidón-Moyano, C., Matilla-Santander, N.,
Balaguer, A., & Martínez-SáNchez, J. M. (2018). Update on thirdhand smoke: A
comprehensive systematic review. Environmental Research, 167, 341-371.
doi:10.1016/j.envres.2018.07.020
Dumenci, L., Matsuyama, R. K., Kuhn, L., Perera, R. A., & Siminoff, L. A. (2013). On the
Validity of the Shortened Rapid Estimate of Adult Literacy in Medicine (REALM) Scale
as a Measure of Health Literacy. Communication Methods and Measures, 7(2), 134-143.
doi:10.1080/19312458.2013.789839

82

Elder, J. P., Ayala, G. X., Parra-Medina, D., & Talavera, G. A. (2009). Health communication in
the Latino community: issues and approaches. Annu Rev Public Health, 30, 227-251.
doi:10.1146/annurev.publhealth.031308.100300
Escoffery, C., Bundy, L., Carvalho, M., Yembra, D., Haardorfer, R., Berg, C., & Kegler, M. C.
(2013). Third-hand smoke as a potential intervention message for promoting smoke-free
homes in low-income communities. Health Educ Res, 28(5), 923-930.
doi:10.1093/her/cyt056
Finseraas, H., Jakobsson, N., & Svensson, M. (2017). Do knowledge gains from public
information campaigns persist over time? Results from a survey experiment on the
Norwegian pension reform *. 16(1), 108-117. doi:10.1017/S1474747215000098
Freire, P. (1970). Pedagogy of the oppressed. Translated by Myra Bergman Ramos. New York:
New York, Herder and Herder.
Freire, P. (2000). Pedagogy of the oppressed (30th anniversary ed. ed.). New York: Continuum.
Furuno, Y., & Sasajima, H. (2015). Medical Comics as Tools to Aid in Obtaining Informed
Consent for Stroke Care. Medicine (Baltimore), 94(26), e1077.
doi:10.1097/MD.0000000000001077
Gillmore MR, Morrison DM, Richey CA, Balassone ML, Gutierrez L, & M., F. (1997). Effects
of a skill-based intervention to encourage condom use among high risk heterosexually
active adolescents. Journal of AIDS Education Prevention, 9 (1 Supplement), 22-43.
Glanz, R., Viswanath, Glanz, Karen, Rimer, Barbara K., & Viswanath, K. (2015). Chapter 1: The
Scope of Health Behavior. In: Glanz, R., Viswanath, Glanz, Karen, Rimer, Barbara K., &
Viswanath, K. Health behavior : Theory, research, and practice. Pages 3 – 22. (Fifth
edition ed. Vol. Fifth edition). San Francisco, CA: Jossey-Bass, a Wiley Brand.
Goniewicz, M. L., Knysak, J., Gawron, M., Kosmider, L., Sobczak, A., Kurek, J., . . . Benowitz,
N. (2014). Levels of selected carcinogens and toxicants in vapour from electronic
cigarettes. Tobacco Control, 23(2), 133. doi:10.1136/tobaccocontrol-2012-050859
Gonzales, M., Malcoe, L. H., Kegler, M. C., & Espinoza, J. (2006). Prevalence and predictors of
home and automobile smoking bans and child environmental tobacco smoke exposure: a
cross-sectional study of U.S.- and Mexico-born Hispanic women with young children.
BMC Public Health, 6, 265.

Goodwin, D., Renee, Cheslack-Postava, K., Santoscoy, S., Bakoyiannis, N., Hasin, D. S.,
Collins, B. N., Wall, M. W. (2018). Trends in Cannabis and Cigarette Use Among
Parents With Children at Home: 2002 to 2015. Pediatrics, 141(6), 1-8.
doi:10.1542/peds.2017-3506
Green, M. C., Strange, J. J., & Brock, T. C. (2002). Narrative Impact: Social and Cognitive
Foundations (M. C. Green, J. J. Strange, & T. C. Brock Eds. First edition ed.). Mahwah,
New Jersey: Lawrence Erlbaum Associates.
Hadden, K. B., Prince, L. Y., Rojo, M. O., Selig, J. P., & McElfish, P. A. (2019). Screening
Patients Who Speak Spanish for Low Health Literacy. Health Literacy Research and
Practice, 3(2), e110-e116. doi:10.3928/24748307-20190408-03
Harvey, J. (1997) Design of a comic book intervention for gay male youth at risk for HIV.
(0094-2499).
He, T., Oks, M., Esposito, M., Steinberg, H., & Makaryus, M. (2017). "Tree-in-Bloom": Severe
Acute Lung Injury Induced by Vaping Cannabis Oil. Annals of the American Thoracic
Society, 14(3), 468. doi:10.1513/AnnalsATS.201612-974LE

83

Hernandez, M. Y., & Organista, K. C. (2013). Entertainment-Education? A Fotonovela? A New
Strategy to Improve Depression Literacy and Help-Seeking Behaviors in At-Risk
Immigrant Latinas. American Journal of Community Psychology, 1-12.
doi:10.1007/s10464-013-9587-1
Hinyard, L. J., & Kreuter, M. W. (2007). Using Narrative Communication as a Tool for Health
Behavior Change: A Conceptual, Theoretical, and Empirical Overview. Health Education
& Behavior, 34(5), 777-792. doi:10.1177/1090198106291963
Holitzki, H., Dowsett, L. E., Spackman, E., Noseworthy, T., & Clement, F. (2017). Health
effects of exposure to second- and third-hand marijuana smoke: a systematic review.
CMAJ open, 5(4), E814. doi:10.9778/cmajo.20170112
Homa, D. M., Neff, L. J., King, B. A., Caraballo, R. S., Bunnell, R. E., Babb, S. D., . . . Wang, L.
(2015). Vital Signs: Disparities in Nonsmokers' Exposure to Secondhand Smoke - United
States, 1999 - 2012. Morbidity and Mortality Weekly Report, 64(4), 103 - 108.
Hovell, M. F., Meltzer, S. B., Wahlgren, D. R., Matt, G. E., Hofstetter, C. R., Jones, J. A., . . .
Pirkle, J. L. (2002). Asthma management and environmental tobacco smoke exposure
reduction in Latino children: A controlled trial. Pediatrics, 110(5), 946-956.
doi:10.1542/peds.110.5.946
Huang, H.-L., Yen, Y.-Y., Lin, P.-L., Chiu, C.-H., Hsu, C.-C., Chen, T., Chen, F.-L. (2012).
Household secondhand smoke exposure of elementary schoolchildren in Southern
Taiwan and factors associated with their confidence in avoiding exposure: a cross-
sectional studyHealth behavior, health promotion and society. BMC Public Health, 12(1),
40. doi:10.1186/1471-2458-12-40
Ingrand, A.Verneau A, C. Silvain C, M. Beauchant M;, & Poitou-Charentes. (2004). Prevention
of viral hepatitis C: assessment of a comic strip-based information campaign targeting
adolescents. European Journal of Public Health, 14(2), 147-150.
Kelder, S.H., Hoelscher, D., and Perry, C. L. (2015). Chapter 9: How individuals, environments,
and health behaviors interact – Social Cognitive Theory. In: Glanz, R., Viswanath, Glanz,
Karen, Rimer, Barbara K., & Viswanath, K. Health behavior : Theory, research, and
practice. Pages 159 – 181. (Fifth edition ed. Vol. Fifth edition). San Francisco, CA:
Jossey-Bass, a Wiley Brand.
Kitchen, P., Kerr, G., E. Schultz, D., McColl, R., & Pals, H. (2014). The elaboration likelihood
model: review, critique and research agenda. European Journal of Marketing, 48(11/12),
2033-2050. doi:10.1108/ejm-12-2011-0776
Jeremy E. Drehmer, M., Deborah J. Ossip, P., Emara Nabi-Burza, M., MS, Nancy A. Rigotti, M.,
Bethany Hipple, M., Heide Woo, M., Jonathan P. Winickoff, M., MPH. (2014).
Thirdhand smoke beliefs of parents. American Academy of Pediatrics, 133(4), 1-7.
Jimenez, D. E., Reynolds, C. F., Alegría, M., Harvey, P., & Bartels, S. J. (2015). The Happy
Older Latinos are Active (HOLA) health promotion and prevention study: study protocol
for a pilot randomized controlled trial. Trials, 16(570). doi:10.1186/s13063-015-1113-3
Johns Hopkins Bloomberg School of Public Health. (2008). Entertainment - Education for Better
Health. Info Reports(17), 1 - 16.
Katz, M., Oldach, B., Goodwin, J., Reiter, P., Ruffin, M., & Paskett, E. (2014). Development and
Initial Feedback About a Human Papillomavirus (HPV) Vaccine Comic Book for
Adolescents. Journal of Cancer Education, 29(2), 318-324. doi:10.1007/s13187-013-
0604-8

84

Kevin Davidson, M., Alison Brancato, M., Peter Heetderks, M., Wissam Mansour, M., Edward
Matheis, M., Myra Nario, M., Daniel Fox, M. (2019). Outbreak of Electronic-Cigarette-
Associated Acute Lipoid Pneumonia - North Carolina, July - August 2019. CDC
Morbidity and Mortality Weekly Report, 68.
King, B. A., Babb, S. D., Tynan, M. A., & Gerzoff, R. B. (2013). National and state estimates of
secondhand smoke infiltration among U.S. multiunit housing residents. Nicotine Tob Res,
15(7), 1316-1321. doi:10.1093/ntr/nts254
Koops Van ’t Jagt, R., Hoeks, J. C. J., Duizer, E., Baron, M., Molina, G. B., Unger, J. B., &
Jansen, C. J. M. (2018). Sweet Temptations : How Does Reading a Fotonovela About
Diabetes Affect Dutch Adults with Different Levels of Literacy? Health Communication,
33(3), 284-290. doi:10.1080/10410236.2016.1258617
Koskan, A., Friedman, D. B., & Hilfinger Messias, D. K. (2010). Health Literacy Among
Hispanics: A Systematic Research Review (1992–2008). Hispanic Health Care
International, 8(2), 65-76. doi:10.1891/1540-4153.8.2.65
Kreuter, M. W., Lukwago, S. N., Bucholtz, R. D., Clark, E. M., & Sanders-Thompson, V.
(2003). Achieving cultural appropriateness in health promotion programs: targeted and
tailored approaches. Health Educ Behav, 30(2), 133-146.
doi:10.1177/1090198102251021
Krogstad, J. M., & Gonzales-Barrera, A. (Last updated March 24, 2015). A majority of English-
speaking Hispanics in the U.S. are bilingual. FacTank News in the Numbers. Retrieved
from https://www.pewresearch.org/fact-tank/2015/03/24/a-majority-of-english-speaking-
hispanics-in-the-u-s-are-bilingual/
Kutner, M., Greenberg, E., Jin, Y., and Paulsen, C. . (2006). The Health Literacy of America’s
Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006–483).
Retrieved from Washington, D.C. :
Lee, S.-Y. D., Bender, D. E., Ruiz, R. E., & Cho, Y. I. (2006). Development of an easy-to-use
Spanish health literacy test.(Informing Decision Makers). Health Services Research,
41(4), 1392. doi:10.1111/j.1475-6773.2006.00532.x
Leung, M. M., Green, M. C., Tate, D. F., Cai, J., Wyka, K., & Ammerman, A. S. (2017). Fight
for Your Right to Fruit: Psychosocial Outcomes of a Manga Comic Promoting Fruit
Consumption in Middle-School Youth. Health Commun, 32(5), 533-540.
doi:10.1080/10410236.2016.1211074
Liebman, A. K., Juarez, P. M., Leyva, C., & Corona, A. (2007). A pilot program using
promotoras de salud to educate farmworker families about the risk from pesticide
exposure. J Agromedicine, 12(2), 33-43. doi:10.1300/J096v12n02_04
Lozano, R. (2019). An American Language: The History of Spanish in the United States.
Berkeley: University of California Press.
Luciana Rizzieri, F., Ana Luiza, Z., & Denise Conceição Mesquita, D. (2016). Thirdhand smoke:
when the danger is more than you can see or smell. Cadernos de Saúde Pública, 32(11).
doi:10.1590/0102-311x00032216
Makadia, L., Roper, P., Andrews, J., & Tingen, M. (2017). Tobacco Use and Smoke Exposure in
Children: New Trends, Harm, and Strategies to Improve Health Outcomes. Current
Allergy and Asthma Reports, 17(8), 1-15. doi:10.1007/s11882-017-0723-0
Martinelli, A. (1999). A theoretical model for the study of active and passive smoking in military
women: An at-risk population. Military Medicine, 164(7), 475-480.
doi:10.1093/milmed/164.7.475

85

Martinelli, A. (2002). Testing a model of exposure to environmental tobacco smoke in military
women in children. Military Medicine, 167(2), 113-120. doi:10.1093/milmed/167.2.113
Matt, G. E., Quintana, P. J., Zakarian, J. M., Fortmann, A. L., Chatfield, D. A., Hoh, E., Hovell,
M. F. (2011). When smokers move out and non-smokers move in: residential thirdhand
smoke pollution and exposure. Tob Control, 20(1), e1. doi:10.1136/tc.2010.037382
Matt, G. E., Quintana, P. J. E., Destaillats, H., Gundel, L. A., Sleiman, M., Singer, B. C., Hovell,
M. F. (2011). Thirdhand tobacco smoke: emerging evidence and arguments for a
multidisciplinary research agenda.(Report). Environmental Health Perspectives, 119(9),
1218. doi:10.1289/ehp.1103500
Mazor, K. M., & Billings-Gagliardi, S. (2003). Does reading about stroke increase stroke
knowledge?: The impact of different print materials. Patient Education and Counseling,
51(3), 207-215. doi:10.1016/S0738-3991(02)00218-5
Meade, C., & Byrd, J. (1989). Patient Literacy and the Readability of Smoking Education
Literature. American Journal of Public Health, 79(2), 204-206.
doi:10.2105/AJPH.79.2.204
Mengyun, Z., Hui, J., Naiyang, S., Chunxiao, D., Donglei, W., Xiaoge, Y., & Xiaoning, L.
(2018). The relationship between health literacy and quality of life: a systematic review
and meta-analysis. Health and quality of life outcomes, 16(1), 1-10. doi:10.1186/s12955-
018-1031-7
Merritt, T. A. M., Jan ; Adamczak, Aleksandra ; Merritt, Travis, & lekarski, P. d. (2012). The
impact of second-hand tobacco smoke exposure on pregnancy outcomes, infant health,
and the threat of third-hand smoke exposure to our environment and to our children.
Przegla ̧ d Lekarski Journal, 69(10), 717-720.
Monsalves, M. J., Mañalich, J., & Fuentes, E. (2016). Validation of the short assessment of
health literacy for spanish-speaking adults test in Chile. Revista medica de Chile, 144(5),
604. doi:10.4067/S0034-98872016000500008

Montaňo, D. and Kasprzyk, D (2015). Chapter 6: Theory of Reasoned Action, Theory of Planned
Behavior, and the Integrated Behavioral Model. In: Glanz, R., Viswanath, Glanz, Karen,
Rimer, Barbara K., & Viswanath, K. Health behavior : Theory, research, and practice.
Pages 95-124. (Fifth edition ed. Vol. Fifth edition). San Francisco, CA: Jossey-Bass, a
Wiley Brand.
Morris Nancy, S., Maclean Charles, D., Chew Lisa, D., & Littenberg, B. (2006). The Single Item
Literacy Screener: Evaluation of a brief instrument to identify limited reading ability.
BMC Family Practice, 7(1), 21. doi:10.1186/1471-2296-7-21
Moyer-Gusé, E. (2008). Toward a Theory of Entertainment Persuasion: Explaining the
Persuasive Effects of Entertainment-Education Messages. Communication Theory, 18(3),
407-425. doi:10.1111/j.1468-2885.2008.00328.x
Murphy, P. W., & et al. (1993). Rapid Estimate of Adult Literacy in Medicine (REALM): A
Quick Reading Test for Patients. Journal of Reading, 37(2), 124-130.
Murphy, S. T., Frank, L. B., Chatterjee, J. S., & Baezconde-Garbanati, L. (2013). Narrative
versus Non-narrative: The Role of Identification, Transportation and Emotion in
Reducing Health Disparities. J Commun, 63(1). doi:10.1111/jcom.12007
National Institutes of Health. (2010). It’s never too late to start exerrcising. (N. I. o. Health Ed.).
Gaithersburg, MD Institutes on Aging.

86

Nguyen, K. H., Gomez, Y., Homa, D. M., & King, B. A. (2016). Tobacco Use, Secondhand
Smoke, and Smoke-Free Home Rules in Multiunit Housing. American Journal of
Preventive Medicine, 51(5), 682-692. doi:10.1016/j.amepre.2016.05.009
Nichter, M., Padmawati, R., & Ng, N. (2010). Developing a smoke free household initiative: an
Indonesian case study. Acta Obstetricia Et Gynecologica Scandinavica, 89(4), 578-581.
doi:10.3109/00016340903578893
Nidia Farias Fernandes, M., Daiane Porto Gautério, A., Bárbara Tarouco Da, S., Deisa Salyse
Dos Reis Cabral, S., Marlene Teda, P., & Fabiana Souza, I. (2017). Functional health
literacy and adherence to the medication in older adults: integrative review. Revista
Brasileira de Enfermagem, 70(4), 868-874. doi:10.1590/0034-7167-2016-0625
Nielsen-Bohlman, L., & Institute of Medicine. (2004). Health Literacy: A Prescription to End
Confusion: National Academies Press.
O'Hegarty, M., Pederson, L. L., Asman, K., Thorne, S. L., & Caraballo, R. S. (2013). Tobacco
use, cessation, and home smoking rules in a Hispanic community. Am J Health Behav,
37(2), 248-256. doi:10.5993/AJHB.37.2.12
Olekalns, M. (2015). The Psychology of Negotiation and Conflict. In (Vol. 16, pp. 423-429).
Passel, J. S., & Cohn, D. V. (2008). U.S. Population Projections: 2005 - 2050. Retrieved from
https://www.pewhispanic.org/2008/02/11/us-population-projections-2005-2050/
Pechero Bishop, W., Craddock Lee, S. J., Sugg Skinner, C., Jones, M. T., McCallister, K., &
Tiro, J. A. (2016). Validity of Single-Item Screening for Limited Health Literacy in
English and Spanish Spekers. American Journal of Public Health, 106(5), 889 - 892.
doi:10.2105/
Peres, F., Moreira Jc Fau - Rodrigues, K. M., Rodrigues Km Fau - Claudio, L., & Claudio, L.
(2006) Risk perception and communication regarding pesticide use in rural work: a case
study in Rio de Janeiro State, Brazil. (1077-3525).
Peter Freebody, & Luke, A. (1990). 'Literacies' Programs: Debates and Demands in Cultural
Context. Prospect, 5, 7 - 16.
Petty, R., & Cacioppo, J. (1983). Source Factors and the Elaboration Likelihood Model of
Persuasion. Advances in Consumer Research, 11, 668.
Petty, R., & Cacioppo, J. (1984). The Effects of Involvement on Responses to Argument
Quantity and Quality: Central and Peripheral Routes to Persuasion. Journal of
Personality and Social Psychology, 46(1), 69. doi:10.1037/0022-3514.46.1.69
Petty, R. E., & Cacioppo, J. T. (1986). The Elaboration Likelihood Model of Persuasion.
Advances in Experimental Social Psychology, 19(C), 123-205. doi:10.1016/S0065-
2601(08)60214-2
Posis, A., Bellettiere, J., Liles, S., Alcaraz, J., Nguyen, B., Berardi, V., Hovell, M. (2019). Indoor
cannabis smoke and children's health. Preventive Medicine Reports, 100853.
doi:10.1016/j.pmedr.2019.100853
Prins, E., & Monnat, S. (2015). Examining Associations between Self-Rated Health and
Proficiency in Literacy and Numeracy among Immigrants and U.S.-Born Adults:
Evidence from the Program for the International Assessment of Adult Competencies
(PIAAC). PLoS One, 10(7), e0130257. doi:10.1371/journal.pone.0130257
Procon.org. (Updated on November 7, 2018). Legal Recreational Marijuana States and DC. Pro
& Cons of Current Issues. Reliable. Nonpartisan. Empowering. Retrieved from
https://marijuana.procon.org/view.resource.php?resourceID=006868

87

Prokhorov, A. V., Hudmon, K. S., Marani, S. K., Bondy, M. L., Gatus, L. A., Spitz, M. R., . . .
Koehly, L. M. (2013). Eliminating second-hand smoke from Mexican-American
households: outcomes from Project Clean Air-Safe Air (CASA). Addict Behav, 38(1),
1485-1492. doi:10.1016/j.addbeh.2012.06.023
Prokhorov;, A. V., Hudmon;, K. S., Marani;, S. K., Bondy;, M. L., Gatus;, L. A., Spitz;, M. R., . .
. Koehly, L. M. (2013). Eliminating second-hand smoke from Mexican-American
households: Outcomes from Project Clean Air-Safe Air (CASA) Addictive Behaviors, 38,
1485-1492.
Protano, C., Manigrasso, M., Avino, P., & Vitali, M. (2017). Second-hand smoke generated by
combustion and electronic smoking devices used in real scenarios: Ultrafine particle
pollution and age-related dose assessment. Environment International, 107, 190-195.
doi:10.1016/j.envint.2017.07.014
Quintana, P. J. E., Hoh, E., Dodder, N. G., Matt, G. E., Zakarian, J. M., Anderson, K. A., . . .
Hovell, M. F. (2019). Nicotine levels in silicone wristband samplers worn by children
exposed to secondhand smoke and electronic cigarette vapor are highly correlated with
child’s urinary cotinine. Journal of Exposure Science & Environmental Epidemiology.
doi:10.1038/s41370-019-0116-7
Rachel Ann Barry, Heikki Hilamo, & Glantz, S. A. (2014). Waiting for the Opportune Moment:
TheTobacco Industry and Marijuana Legalization. The Milbank Quarterly: A
Multidisciplinary Journal of Population Health and Health Policy, 92(2), 207-242.
Ratzan, S. C. (2001). Health literacy: communication for the public good. Health Promotion
International, 16(2), 207-214. doi:10.1093/heapro/16.2.207
Redmond, C. A., Hamilton, F. A., Kay, E. J., Worthington, H. V., & Blinkhorn, A. S. (2001). An
investigation into the value and relevance of oral health promotion leaflets for young
adolescents. International Dental Journal, 51(3), 164-168. doi:10.1002/j.1875-
595X.2001.tb00834.x
Rodriguez, V. M., Conway, T. L., Woodruff, S. I., & Edwards, C. C. (2003). Pilot test of an
assessment instrument for Latina community health advisors conducting an ETS
intervention. J Immigr Health, 5(3), 129-137.
Rosen, L. J., Myers, V., Winickoff, J. P., & Kott, J. (2015). Effectiveness of Interventions to
Reduce Tobacco Smoke Pollution in Homes: A Systematic Review and Meta-Analysis.
International Journal of Environmental Research and Public Health, 12(12).
doi:10.3390/ijerph121215038
Salviati, C. (2017). The Racial Divide in Homeownership. Retrieved from
https://www.apartmentlist.com/rentonomics/racial-divide-homeownership/
Sarkar, M., Asti, L., Nacion, K. M., & Chisolm, D. J. (2016). The Role of Health Literacy in
Predicting Multiple Healthcare Outcomes Among Hispanics in a Nationally
Representative Sample: A Comparative Analysis by English Proficiency Levels. J
Immigr Minor Health, 18(3), 608-615. doi:10.1007/s10903-015-0211-3
Sarkar, U., Schillinger, D., Lopez, A., & Sudore, R. (2011). Validation of self-reported health
literacy questions among diverse English and Spanish-speaking populations. J Gen Intern
Med, 26(3), 265-271. doi:10.1007/s11606-010-1552-1
Savas, L. S., Mullen, P. D., Hovell, M. F., Escoffrey, C., Fernandez, M. E., Jones, J. A., Kegler,
M. C. (2017). A Qualitative Study Among Mexican Americans to Understand Factors
Influencing the Adoption and Enforcement of Home Smoking Bans. Nicotine & tobacco
research., 19(12), 1465-1472. doi:10.1093/ntr/ntw270

88

Sberna Hinojosa, M., Hinojosa, R., Nelson, D. A., Delgado, A., Witzack, B., Gonzalez, M.,
Meurer, L. (2010). Salud de la mujer: using fotonovelas to increase health literacy among
Latinas. Progress in Community Health Partnerships, 4(1), 25-30.
doi:10.1353/cpr.0.0106
Schane, R.E., Prochaska, J.J., and Glanz, S.A. (2013). Counseling nondaily smokers about
secondhand smoke as a cessation message: a pilot randomized trial. Nicotine & tobacco
research., 15(2), 334-342.
Sestir, M., & Green, M. C. (2010). You are who you watch: Identification and transportation
effects on temporary self-concept. Social Influence, 5(4), 272-288.
doi:10.1080/15534510.2010.490672
Shen, L., Condit, C. M., & Wright, L. (2009). The psychometric property and validation of a
fatalism scale. Psychology & Health, 24(5), 597-613. doi:10.1080/08870440801902535
Slovic, P., Finucane, M. L., Peters, E., & Macgregor, D. G. (2004). Risk as Analysis and Risk as
Feelings: Some Thoughts about Affect, Reason, Risk, and Rationality. Risk Analysis,
24(2), 311-322. doi:10.1111/j.0272-4332.2004.00433.x
Stanley, D. (2003). What do we know about social cohesion: the research perspective of the
Federal Government's Social Cohesion Research Network (1). Canadian Journal of
Sociology, 28(1), 5. doi:10.2307/3341872
StataCorp. (2013). Stata Statistical Software: Release 13. College Station, TX.
Stormacq, C., Van Den Broucke, S., & Wosinski, J. (2018). Does health literacy mediate the
relationship between socioeconomic status and health disparities? Integrative review.
Health Promotion International. doi:10.1093/heapro/day062
Toku, M. (2001). What is Manga? The Influence of Pop Culture in Adolescent Art. Art
Education, 54(2), 11-17.
Toroyan, T., & Reddy, P. S. (2005). Participation of South African Youth in the Design and
Development of AIDS Photocomics. International Quarterly of Community Health
Education, 25(1), 149-163. doi:10.2190/FG42-PQ5G-5352-2238
Unger, J. B, Molina, G., & Baron, M. (2009). Evaluation of Sweet Temptations, a Fotonovela for
Diabetes Education. Hispanic Health Care International, 7(3), 145-152.
doi:10.1891/1540-4153.7.3.145
Unger, J. B., Boley Cruz, T., Baezconde - Garbanati, L., Baron, M., Molina, G. B., Padilla, E.,
Vogel, R. (2014). Marta on a Mission. University of Southern California.
Unger, J. B., Soto, D. W., Baezconde - Garbanati, L., Delgado Rendon, A., & Cruz, T. B. (2019).
Empowering Hispanic multiunit housing residents to advocate for
smokefree policies: A randomized controlled trial of a culturally tailored fotonovela
intervention. Journal of Health Equity. Vol 3 (1): 198 – 204. Doi: 10.1089/heq.2018.0098
Unger, J. B., Soto, D. W., Rendon, A. D., Baezconde-Garbanati, L., & Cruz, T. B. (2019).
Empowering Hispanic Multiunit Housing Residents to Advocate for Smokefree Policies:
A Randomized Controlled Trial of a Culturally Tailored Fotonovela Intervention. Health
Equity, 3(1), 198-204. doi:10.1089/heq.2018.0098
U.S. Department of Health and Human Services. (2006). The Health Consequences of
Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Center for
Disease Control and Prevention, 1 - 685.
U.S. Department of Health and Human Services. (2014). The Health Consequences of Smoking—
50 Years of Progress: A Report of the Surgeon General. Retrieved from Atlanta, GA.

89

U.S. Department of Health and Human Services. (2019). Health Communication and Health
Information Technology. Healthy People 2020 Objectives. Retrieved from
https://www.healthypeople.gov/2020/topics-objectives/topic/health-communication-and-
health-information-technology/objectives
U.S. Department of Housing Authorities. (2016). Implementing the Department of Housing and
Urban Development's Smoke Free Policy in Public Housing. Retrieved from Washington,
DC.
Valle, R., Yamada, A.-M., & Matiella, A. C. (2006). Fotonovelas. Clinical Gerontologist, 30(1),
71-88. doi:10.1300/J018v30n01_06
Viswam, D., Trotter, S., Burge, P. S., & Walters, G. I. (2018). Respiratory failure caused by
lipoid pneumonia from vaping e-cigarettes. BMJ Case Reports, 2018. doi:10.1136/bcr-
2018-224350
Waldrop-Valverde, D., Jamale Murden, R., Guo, Y., Holstad, M., & Ownby, R. L. (2018). Racial
Disparities in HIV Antiretroviral Medication Management are Mediated by Health
Literacy. Health Literacy Research and Practice, 2(4), e205-e213.
doi:10.3928/24748307-20180925-01
Waldrop-Valverde, P., Raphiel Jamale Murden, B., Ying Guo, P., Marcia Holstad, D., RN, FNP-
BC;, & Raymond L. Ownby, M., PhD. (2018). Racial Disparities in HIV Antiretroviral
Medication Management are Mediated by Health Literacy. Health Literacy and Research
Practice, 2(4), e205 - e213.
Waziry, R., Jawad, M., Ballout, R. A., Al Akel, M., & Akl, E. A. (2017). The effects of
waterpipe tobacco smoking on health outcomes: an updated systematic review and meta-
analysis. International Journal of Epidemiology, 46(1), 32-43. doi:10.1093/ije/dyw021

Wilkin, H. A., Valente, T. W., Murphy, S., Cody, M. J., Huang, G., & Beck, V. (2007). Does
entertainment-education work with Latinos in the United States? Identification and the
effects of a telenovela breast cancer storyline. J Health Commun, 12(5), 455-469.
doi:10.1080/10810730701438690
Wilson, E. A. H., Makoul, G., Bojarski, E. A., Bailey, S. C., Waite, K. R., Rapp, D. N., Wolf, M.
S. (2012). Comparative analysis of print and multimedia health materials: A review of the
literature. Patient Education and Counseling, 89(1). doi:10.1016/j.pec.2012.06.007
Woo, B., Kravitz-Wirtz, N., Sass, V., Crowder, K., Teixeira, S., & Takeuchi, D. (2019).
Residential Segregation and Racial/Ethnic Disparities in Ambient Air Pollution. Race
and Social Problems, 11(1), 60-67. doi:10.1007/s12552-018-9254-0

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Appendix A. Survey Fotonovela Post-Test in English

Good afternoon, my name is NAME and this is NAME. We are from the University of Southern
California and we are working on a project about tobacco smoke in apartment buildings. About
6 months ago you took a survey with us about this topic. We hope to learn more about residents’
experience with tobacco and smoking. We hope you will take the follow up survey we
mentioned when you took the first survey. You will get a $15.00 gift card for this survey. You
will be given your gift card at the end of this survey. May I ask you a few questions?

Is NAME OF PARTICIPANT available? Note to callers/data
Is this the same person who completed the survey at baseline? Y/N
1. Birthdate:
Day _________
Month _______
Year ________
About you

2. How many people live in your home?
Adults:____________
Children under 18yrs:__________
Tobacco Use
The next questions ask about tobacco use in your home.

3. Has anyone who lives with you used any of the following tobacco products in the last 30
days? Choose all that apply.
1. Cigarettes
2. Smokeless tobacco, such as chewing tobacco, snuff, dip, or snus
3. Cigars, cigarillos, or filtered cigars
4. Blunts/blunt wraps
5. E-cigarettes
6. Any other form of tobacco (Please fill in type of tobacco)
7. No one who lives with me now used any form of tobacco in the last 30 days
8. Don’t know

4. Which of the following people in your home used tobacco products in the last 30 days?
1, You
2, Your spouse/partner
3, Your child
4, Your parent
5, Other relative
6, Roommate
7, Guests
8, No one
9, Other: __________________________

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APARTMENT TOBACCO SMOKE
These next few questions ask about rules about using tobacco inside your home. Please think
about everyone who might be in your home including children, adults, visitors, or guests.

5. Does anyone ever smoke tobacco inside your home?
o Yes (If yes, please list who)
o No if No, suggest a SKIP to 7

5a. How often does this person smoke tobacco inside your home?
o Daily
o A few times a week
o Once a week
o A few times a month
o Once a month
o Never

6. Which of the following people use tobacco inside your home? Choose all that apply.
1, You
2, Your spouse/partner
3, Your child
4, Your parent
5, Other relative
6, Roommate
7, Guests
8, No one
9, Other: __________________________

7. Is any tobacco smoking ever allowed inside your home?
o Yes
o No

8. Since the last survey, about 6 months ago, how often did tobacco smoke enter your home from
somewhere else around the building?
1, Daily
2, A few times a week
3, Once a week
4, A few times a month
5, Once a month
6, Never

9. Does the smell of tobacco smoke in your home bother you?
1, Yes, a lot
2, Yes, a little
3, No, it does not bother me
4, No, I don’t have the smell of tobacco smoke in my home

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10. Since the last survey, about 6 months ago, have you smelled marijuana smoke in your home
that came from outside?
1, Yes
2, No
3, Prefer not to answer

11. Since the last survey, about 6 months ago, have you smelled marijuana smoke anywhere in
or around your building?
o Yes
o No
o Prefer not to answer

12. Since the last survey, about 6 months ago, have you smelled tobacco smoke in any of the
following areas in or around your building: (check all that apply)
1, Hallway
2, Laundry room
3, Lobby
4, Lounge or common area
5, Patio or balcony
6, Playground/Park
7, Other:__________________________
8, None

13. How annoying do you find other people's tobacco smoke?
1, Not annoying at all
2, A little annoying
3, Very annoying
4, Extremely annoying

These next questions will ask about tobacco smoking rules in and around your building.
14. Are there any rules against smoking in or around your building?
1, Yes (SKIP PATTERN = (Are these rules against tobacco smoking, are these rules against
e-cig/vaping, are these rules against marijuana smoke)
2, No (for those who answer “No” suggest a SKIP pattern to 22)
3, Don’t know

14a. Are these rules against tobacco smoking?
o Yes
o No
o Don’t know

14b. Are these rules against e-cig/vaping?
o Yes
o No
o Don’t know

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14c. Are these rules against marijuana smoke?
o Yes
o No
o Don’t know

15. Is smoking allowed in outdoor common areas?
o Yes
o No
o Don’t know

16. Is smoking allowed in indoor common areas like hallways and laundry rooms?
o Yes
o No
o Don’t know

17. Is smoking allowed inside the apartment units?
o Yes
o No
o Don’t know

18. Does your building have any other non-smoking rule?
o Yes (Describe)
o No (skip to 22….)
o Don’t know

19. Do people break the non- smoking rules outside your building?
o Yes, all the time
o Yes, most of the time
o Yes, some of the time
o No

20. Do people break the non- smoking rules in your building?
o Yes, all the time
o Yes, most of the time
o Yes, some of the time
o No

21. What happens to someone if they break the non-smoking rules?
o Someone gets mad at them
o Someone reports them
o They have to move out
o Nothing happens
o Other: _______________

22. Would you favor a rule in your building that bans tobacco smoking in all areas, including
personal living spaces, such as balconies and patios?

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o Yes, definitely
o Yes, probably
o Probably not
o Definitely not

23. Would you favor a rule in your building that bans e-cigarette smoking/vaping in all areas,
including personal living spaces, such as balconies and patios?
o Yes, definitely
o Yes, probably
o Probably not
o Definitely not

24. Would you favor a rule in your building that bans Marijuana smoking in all areas, including
personal living spaces, such as balconies and patios?
o Yes, definitely
o Yes, probably
o Probably not
o Definitely not

These next questions will ask about the smell of tobacco smoke.
25. Since the last survey, about 6 months ago, how often did you smell tobacco smoke in your
home or building that came from furniture, clothes, or other things?
o Daily
o A few times a week
o Once a week
o A few times a month
o Once a month
o Never (skip to 28 -double check! )

26. Does the smell of tobacco ash and dust in your furniture, carpets and curtains bother you?
o Yes, a lot
o Yes, a little
o No, it does not bother me
o No, I don’t have the smell of tobacco smoke in my home

27. Since the last survey, about 6 months ago, did anything like chairs, carpet, or curtains smell
like tobacco in any of the following areas in or around your building:
o Hallway
o Laundry room
o Lobby
o Lounge or common area
o Patio or balcony
o Playground/Park
o Other:__________________________
o None

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SELF EFFICACY
28. I feel confident that I can protect my home from secondhand smoke.
o Strongly agree
o Agree
o Disagree
o Strongly disagree

29. I feel certain that I can keep ashes and dust from smoke off my furniture, carpets, and
curtains.
o Strongly agree
o Agree
o Disagree
o Strongly disagree

30. If my neighbor’s tobacco smoke bothered me, I feel confident that I could talk to them about
it.
o Strongly agree
o Agree
o Disagree
o Strongly disagree

31. I feel certain that I could talk to my landlord about secondhand smoke in the building.
o Strongly agree
o Agree
o Disagree
o Strongly disagree

32. I feel confident that I could talk to my landlord about the smell of smoke on furniture, carpets
and curtains.
o Strongly agree
o Agree
o Disagree
o Strongly disagree

33. I have some good ideas about how to get tobacco smoking stopped in places in and around
my building.
o Strongly agree
o Agree
o Disagree
o Strongly disagree

COMMUNITY EFFICACY
34. My neighbors and I could convince our landlord to make a smoke-free rule.
o Strongly agree
o Agree

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o Disagree
o Strongly disagree

35. I believe that my neighbors and I can protect our building from tobacco smoke.
o Strongly agree
o Agree
o Disagree
o Strongly disagree

36. I believe that my neighbors and I can work together to protect our building from tobacco
smoke.
o Strongly agree
o Agree
o Disagree
o Strongly disagree

PERCEIVED BARRIERS
37. Which of the following make it hard for you to protect yourself from secondhand smoke?
Check all that apply
o I have more important problems
o I don’t know how to protect myself/my family
o I can’t control other people’s actions
o I don’t feel comfortable telling people not to smoke
o I don’t want to make trouble in my building
o I don’t want the smokers to get angry at me
o I’m worried that I’ll get evicted if I complain
o There is no rule against smoking
o The manager is not helpful
o Other: _______________________________________________

38 Open – ended question: What do you think can help you protect your home from secondhand
smoke? (Allow for multiple open responses).

INTENTIONS AND BEHAVIOR

39. Do you intend to talk to your landlord about protecting your apartment from secondhand
smoke?

o Yes, in the next month
o Yes, in the next 6 months
o Yes, but not in the next 6 months
o No, never
o No, it’s not a problem

40. Do you intend to talk to your landlord about the smell of tobacco on furniture, carpets and
curtains?

97

o Yes, in the next month
o Yes, in the next 6 months
o Yes, but not in the next 6 months
o No, never
o No, it’s not a problem

41. Do you intend to talk to your neighbors about protecting your apartment from secondhand
smoke?

o Yes, in the next month
o Yes, in the next 6 months
o Yes, but not in the next 6 months
o No, never
o No, it’s not a problem

42. Since the last survey, about 6 months ago, did you talk to your landlord about protecting
your apartment from secondhand smoke?

o Yes
o No
o Prefer not to answer

43. Since the last survey, about 6 months ago, did you talk to your landlord about the smell of
tobacco on furniture, carpets and curtains?

o Yes
o No
o Prefer not to answer

44 Since the last survey, about 6 months ago, did you talk to your neighbors about protecting
your apartment from secondhand smoke?

o Yes
o No
o Prefer not to answer

45. Since the last survey, about 6 months ago, have you ever asked someone not to smoke in or
around your apartment building?
o Yes
o No (Skip to 48)

46. The last time you asked someone not to smoke, who was that person?
Check all that apply

o Spouse or partner

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o Parent
o Child
o Other relative
o Friend
o Co-worker
o Other known person
o Stranger

47. What was the main reason you asked that person not to smoke?
Check all that apply

o Smoke was annoying to you
o Concerned about health effects of secondhand smoke
o Smoking was illegal
o Concerned about the smoker’s health
o Concerned about your own health (respondent’s health)
o Other: ___________________________

ATTITUDES
Please tell me if you agree or disagree with the following.
48. Outdoor common areas in apartment or condo complexes, such as pools, common area
patios, and walkways, should have areas where people can smoke.
o Strongly agree
o Agree
o Disagree
o Strongly disagree

49. It is best to not bother smokers as long as they are smoking outside the building.
o Strongly agree
o Agree
o Disagree
o Strongly disagree

50. Neighbors should confront smokers directly when secondhand smoke enters their apartments.
o Strongly agree
o Agree
o Disagree
o Strongly disagree

51. It is okay for residents to knock on neighbors’ doors to organize a meeting about secondhand
smoke problems in their buildings.
o Strongly agree
o Agree
o Disagree
o Strongly disagree

99

52. If there is a smoking problem in my building, it is best to talk to my neighbors about it.
o Strongly agree
o Agree
o Disagree
o Strongly disagree

53. If there is a smoking problem in my building, I should just move to another apartment
building.
o Strongly agree
o Agree
o Disagree
o Strongly disagree

KNOWLEDGE
For the next questions answer if you think the statement is true, false, or you don’t know.
54 Smoke from other people’s cigarettes can cause asthma attacks.
o True
o False
o Don’t know

55. After smoke settles into my couch and rug, it is no longer harmful to my health.
o True
o False
o Don’t know

56. Other people’s marijuana smoke is harmful for me if I breathe it in.
o True
o False
o Don’t know

57. Third Hand Smoke will go away after the landlord cleans the apartment.
o True
o False
o Don’t know

58. Secondhand Smoke is more harmful to people with asthma than people without asthma
o True
o False
o Don’t know

59. Since smoking cigarettes is legal, my neighbors have the right to smoke in & around the
building.
o True
o False

100

o Don’t know

60. A landlord needs permission from the city to make a no smoking rule.
o True
o False
o Don’t know

61. People have the right to ask their landlord/manager to pass a smoke-free building rule.
o True
o False
o Don’t know

62. Smoke from outside my windows can make a child sick.
o True
o False
o Don’t know

63. Apartments cost more to clean after a smoker moves out.

o True
o False
o Don’t know

64. An owner can rent units for more money if the apartment is smoke free.
o True
o False
o Don’t know

65. The owner will have lower costs for fire insurance if the apartment is smoke-free.
o True
o False
o Don’t know

66. How can people keep their family safe from smoke?
Please check all that apply.

o Ask people not to smoke near your family
o Ask family members to quit smoking
o Ask people to smoke farther away
o Ask for a no-smoking rule in your building
o Open the window when someone smokes in your car
o Vacuum your apartment after someone smokes in your home
o Ask for a smoking area further from your unit
o Don’t know

67. Apartments cost the same amount to clean for smokers and non-smokers.

101

o True
o False
o Don’t know

68. Have you ever heard of third hand smoke?

o Yes
o No

Demographics – at end of baseline survey only (MIGHT WANT TO KEEP SOME OF
THIS FOR POST-SURVEY)
69. Last year’s household income:

o Less than $10,000
o $10,000 to $19,999
o $20,000 to $29,999
o $30,000 to $39,999
o $40,000 to $49,999
o $50,000 to $59,999
o $60,000 to $69,999
o $70,000 or more

70. Birthdate:
Day _________
Month _______
Year ________
71. Current age if DOB missing: ___________
Theories Section
Comparison group (Booklet) gets these sections as well as the intervention (Fotonovela)
Control group (Nothing) does not get these sections
For the following questions, think back to the educational booklets that we gave you about
secondhand and third hand smoke.
Dissemination Questions
72. Did you read the booklet/s?
o Yes all of it
o Yes some of it
o No (Skip to 74)
o I don’t remember

73 What was the main message in the booklet? (Allow only 1 response)

o Apartments are becoming more expensive to rent
o Smoke from other people’s tobacco cigarettes can be bad for my health
o Neighbors can vote to allow smoking inside smoke free apartment buildings
o Classes to quit smoking are offered in every city

102

74. Please think about the reading material that you received in this study about 6 months
ago. What happened to it? (Answer multiple choice)

o I read it
o I threw it away immediately
o I brought it home but threw it away later
o I kept it so I could read it again later
o I gave it to someone else
o I left it in a place where someone else would see it
o I planned to give it to someone, but I didn’t
o I talked to somebody about the information in the booklet
o Other:
o SKIP pattern –those who did not read booklet: SKIP to 95 SOCIAL COGNITIVE
THEORY
o 75-95 would not apply if they did not materials

TRANSPORTATION

On a scale from 1 to 10, where 1 means strongly disagree and 10 means strongly agree, please
indicate how much you agree with each of the following statements.

75. (T1) After I finished reading the booklet, I found it easy to put it out of my mind.

1 2 3 4 5 6 7 8 9 10
Strongly disagree Strongly agree

76. (T2) I could picture myself in the scenes shown in the booklet.

1 2 3 4 5 6 7 8 9 10
Strongly disagree Strongly agree

77. (T3) I found my mind wandering while reading the booklet.

1 2 3 4 5 6 7 8 9 10
Strongly disagree Strongly agree

78.(T4) I found myself thinking of ways the booklet could have turned out differently.

1 2 3 4 5 6 7 8 9 10
Strongly disagree Strongly agree

103

79. (T5) I wanted to learn how the booklet ended.

1 2 3 4 5 6 7 8 9 10
Strongly disagree Strongly agree

80. (T6) I was mentally involved in the booklet while reading it.

1 2 3 4 5 6 7 8 9 10
Strongly disagree Strongly agree

81. (T7) The events in the booklet are relevant to my everyday life.

1 2 3 4 5 6 7 8 9 10
Strongly disagree Strongly agree

82. (T8) The events in the booklet have changed my life.

1 2 3 4 5 6 7 8 9 10
Strongly disagree Strongly agree

83. (T9) While I was reading the booklet, activity going on in the room around me was
on my mind.

1 2 3 4 5 6 7 8 9 10
Strongly disagree Strongly agree

84. (T10) While I was reading the booklet, I could easily picture the events in it taking
place.

1 2 3 4 5 6 7 8 9 10
Strongly disagree Strongly agree

IDENTIFICATION (ONLY FOTONOVELA GROUP)

On a scale from 1 to 10, where 1 means not at all and 10 means a great deal...

85. (I1)How much did you like the characters in the story?

1 2 3 4 5 6 7 8 9 10
Not at all A great deal

104

86. (I2) How much do you feel like you know the characters?

1 2 3 4 5 6 7 8 9 10
Not at all A great deal

87. (I3) How similar are you to one of the characters?

1 2 3 4 5 6 7 8 9 10
Not at all A great deal

88. (I4) How much would you like to be like one of the characters?

1 2 3 4 5 6 7 8 9 10
Not at all A great deal

Transportation: Craftsmanship
89. On a scale from 1 to 10, 10 being the best, how well made were the booklets?

1 2 3 4 5 6 7 8 9 10
Not very well made (Poor quality) Very well made (Great quality)

Transportation: Emotion (Treatment groups 1 and 2, not control)
On the basis of the results, two variables can be used for subsequent analysis: one for negative
emotions (anger, sadness, disgust, and fear; and one for positive emotion (happiness) from
Murphy (2013). We could just ask 2 or 3 of these (Anger, sadness, and happiness*).
90. (E1) Did the booklet make you feel angry? (Negative emotion*)
1 2 3 4 5 6 7 8 9 10
Not at all Extremely

91. (E2) Did the booklet make you feel sad? (Negative emotion*)
1 2 3 4 5 6 7 8 9 10
Not at all Extremely

92. (E3) Did the booklet make you feel disgusted? (Negative emotion)
1 2 3 4 5 6 7 8 9 10
Not at all Extremely

93. (E4) Did the booklet make you feel afraid? (Negative emotion)
1 2 3 4 5 6 7 8 9 10
Not at all Extremely

94. (E5) Did the booklet make you feel happy? (Positive emotion*)

105

1 2 3 4 5 6 7 8 9 10
Not at all Extremely

95. (E6) Did the booklet make you feel surprised?
1 2 3 4 5 6 7 8 9 10
Not at all Extremely

Social Cognitive Theory (All groups)
Social Cohesion (A subscale of Collective Efficacy)
1. People in this neighborhood can be trusted

o Strongly agree
o Agree
o Neutral, neither agree nor disagree
o Disagree
o Strongly disagree

2. This is a close-knit neighborhood

o Strongly agree
o Agree
o Neutral, neither agree nor disagree
o Disagree
o Strongly disagree

3. People around here are willing to help their neighbors (#97)

o Strongly agree
o Agree
o Neutral, neither agree nor disagree
o Disagree
o Strongly disagree

4. People in this neighborhood generally don't get along with each other (#98)

o Strongly agree
o Agree
o Neutral, neither agree nor disagree
o Disagree
o Strongly disagree

5. People in this neighborhood do not share the same values (#99)

o Strongly agree

106

o Agree
o Neutral, neither agree nor disagree
o Disagree
o Strongly disagree

Frequency of interpersonal neighborhood communication
101. On a scale from 1 to 10, where 1 represents ‘‘never’’ and 10 ‘‘all the time,’’ how often do
you have discussions with other people about things happening in your neighborhood?
1 2 3 4 5 6 7 8 9 10
Never All the time

Outcome expectancies
102. If I were to ask my manager to pass a non-smoking rule in the building: (Check any of the
following situations that would occur):
o Manager would not pass a non-smoking rule (N)
o Manager would make a smoking area away from the living spaces (P)
o Manager would not do anything (Negative)
o Manager would ask the city for help in passing a rule (P)

103. If I were to ask my manager to pass a non-smoking rule in the building: (Check any of the
following situations that would occur):
o I would enjoy talking to my manager about this issue (P)
o It would make it harder for me to get along with him/her (N)
o It would help me to deal with the problems or stress (P)
o It would make it harder for me to deal with this issue (N)

104. If I were to ask my neighbors to pass a non-smoking rule in the building: (Check any of the
following situations that would occur):
o Smoking neighbors would get angry at me (N)
o Most neighbors would support me (P)
o A neighbor would hurt me, my family, or our property (N)
o A neighbor would say mean things to me or my family

Abstract (if available)

Linked assets

University of Southern California Dissertations and Theses

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