Smoking remains a leading cause of premature, preventable death in South Africa killing 44 000 South Africans each year. Through the introduction of comprehensive tobacco control policies, the South African government has tried to reduce the death toll and a significant reduction in tobacco use has been recorded since its peak in the 1990’s. Smoking among women, however have remained unchanged, which calls for actions. Pregnant mothers are specifically vulnerable as their smoking detrimentally affects their own health as well as the health of their babies. This thesis gives an account of the role the antenatal care system could play in reducing the burden caused by cigarette smoking.   The overall aim was to contribute to an understanding of how a person-centred approach to smoking cessation among disadvantaged pregnant women with high smoking rates may influence smoking behaviour. The specific objectives were to confirm the high smoking rates of the target population, assess their readiness to quit, explore existing barriers and promoting factors towards smoking cessation efforts within the public antenatal health care system, and to qualitatively assess the attitudes and perceptions of disadvantaged pregnant women regarding a personcentred smoking cessation intervention.   The high smoking rates of the target population was confirmed based on a cross-sectional study at antenatal clinics in four main cities of South Africa. It focused on the prevalence of smoking during pregnancy and used the stages of change theory to identify their readiness to quit. Additional questions concerned pregnancy related disease experiences, socio-economic determinants of continued smoking as well as attitudes towards the existing clinic services and its possible role in smoking cessation. A qualitative interview study analyzed more in-depth barriers for two-way communication between pregnant mothers and midwives. Both these studies informed the design and development of a person-centred smoking cessation intervention delivered at four public sector antenatal clinics in Cape Town. The intervention was subjected to a comprehensive evaluation based on a combination of quantitative and qualitative measures. This thesis utilizes data from the qualitative process assessment part, comprising individual interviews and focus group discussions with pregnant women during the implementation period of the intervention.   The survey results pointed out a high prevalence of smoking of 46% amongst disadvantaged pregnant women, with varying readiness for behaviour change. Most women were in the contemplation stage of behaviour change and thus ready to quit. Many of the women felt positive about the role of the midwife as an antenatal care provider, but they did not have confidence in midwives concerning encouraging or supporting women to change addictive behaviour be it smoking, alcohol or other illegal substances. The qualitative research highlighted the need for revised curricula for health education and counselling. The analysis illustrated how the current situation created tension between clinic staff and pregnant women making women feel unworthy and thus leaving little room for changing behaviour. The in-depth interviews and the focus group discussions provided an analytical account of how the person-centred approach in this population was perceived by the women themselves. It illustrated that a multifaceted intervention programme, using peer counselors and educational material designed specifically for a given target population, can successfully bring about behaviour change. The intervention succeeded in shifting women’s perceptions of hopelessness into feelings of being empowered to face their addictions and competent to make a change. Though the intervention meant greater rapport with the midwives, involving peer counsellors was rated highly by the participating women. The women reported having used the educational material and attached a great value to the appropriateness of the material to their life situations, and the effectiveness of having it combined with counselling from a peer counsellor. This qualitative evaluation showed the importance of a multifaceted intervention approach, in helping women identify with their behaviour change.   The thesis highlights the importance of designing smoking cessation interventions that are specific to the needs of target populations. When smoking cessation efforts are included into routine antenatal services it is important that the target group inform the nature and specific components of the intervention.

Adolescent peer counselling as a social support strategy to assist adolescents to cope with stress in their peer group provides the focus for the present thesis. The prosocial behaviour of providing emotional and psychological support through the use of helping conversations by young people is examined. Current programs for training adolescent peer counsellors have failed to discover what skills adolescents bring to the helping conversation. They ignore, actively discourage, and censor, some typical adolescent conversational helping behaviours and idiosyncratic communication processes. Current programs for training adolescent peer counsellors rely on teaching microcounselling skills from adult counselling models. When using this approach, the adolescent peer helper training literature reports skill implementation, role attribution and status differences as being problematic for trained adolescent peer counsellors (Carr, 1984; de Rosenroll, 1988; Morey & Miller, 1993). For example Carr (1984) recognised that once core counselling skills have been reasonably mastered that young people " may feel awkward, mechanical or phoney" (p. 11) when trying to implement the new skills. Problematic issues with regard to role attribution and status differences appear to relate to the term 'peer counsellor' and its professional expectations, including training and duties (Anderson, 1976; Jacobs, Masson & Vass, 1976; Myrick, 1976). A particular concern of Peavy (1977) was that for too many people counselling was an acceptable label for advice giving and that the role of counsellor could imply professional status. De Rosenroll (1988) cautioned against creating miniature mirror images of counselling and therapeutic professionals in young people. However, he described a process whereby status difference is implied when a group of adolescent peer counsellors is trained and invited to participate in activities that require appropriate ethical guidelines including competencies, training, confidentiality and supervision. While Carr and Saunders (1981) suggest, "student resentment of the peer counsellor is not a problem" they go on to say, "this is not to say that the problem does not exist" (p. 21). The authors suggest that as a concern the problem can be minimised by making sure the peer counsellors are not 'forced' on the student body and by providing opportunities for peer counsellors to develop ways of managing resentment. De Rosenroll (1988) acknowledges that the adolescent peer counsellor relationship may fall within a paraprofessional framework in that a difference in status may be inferred from the differing life experiences of the peer counsellor when compared with their student peers. The current project aimed to discover whether the issues of skill implementation, role attribution and status differences could be addressed so that adolescent peer counselling, a valuable social support resource, could be made more attractive to, and useful for adolescents. The researcher's goal was to discover what young people typically do when they help each other conversationally, what they want to learn that would enhance their conversational helping behaviour, and how they experience and respond to their role as peer counsellor, and then to use the information obtained in the development of an adolescent-friendly peer counsellor training program. By doing this, the expectation was that the problematic issues cited in the literature could be addressed. Guided by an ethnographic framework the project also examined the influence of an adolescent-friendly peer counsellor training program on the non-peer counsellor students in the wider adolescent community of the high school. Three sequential studies were undertaken. In Study 1, the typical adolescent conversational and communications skills that young people use when helping each other were identified. In addition, those microcounselling skills that young people found useful and compatible with their typical communication processes were identified. In Study 2, an intervention research process was used to develop, deliver, and evaluate an adolescent-friendly peer counsellor training program which combined typical adolescent helping behaviours with preferred counselling microskills selected by participants in Study 1. The intervention research paradigm was selected as the most appropriate methodology for this study because it is designed to provide an integrated perspective for understanding, developing, and examining the feasibility and effectiveness of innovative human services interventions (Bailey-Dempsey & Reid, 1996; Rothman & Thomas, 1994). Intervention research is typically conducted in a field setting in which researchers and practitioners work together to design and assess interventions. When applying intervention research methodology researchers and practitioners begin by selecting the problem they want to remedy, reviewing the literature, identifying criteria for appropriate and effective intervention, integrating the information into plans for the intervention and then testing the intervention to reveal the intervention's strengths and flaws. Researchers then suggest modifications to make the intervention more effective, and satisfying for participants. In the final stage of intervention research, researchers disseminate information about the intervention and make available manuals and other training materials developed along the way (Comer, Meier, & Galinsky, 2004). In Study 2 an adolescent-friendly peer counsellor training manual was developed. Study 3 evaluated the impact of the peer counsellor training longitudinally on the wider school community. In particular, the project was interested in whether exposure to trained peer counsellors influenced students who were not peer counsellors with regard to their perceptions of self-concept, the degree of use of specific coping strategies and on their perceptions of the school climate. Study three included the development of A School Climate Survey which focused on the psychosocial aspects of school climate from the student's perspective. Two factors which were significantly correlated (p<.01) were identified. Factor 1 measured students' perceptions of student relationships, and Factor 2 measured students' perceptions of teachers' relationships with students. The present project provides confirmation of a number of findings that other studies have identified regarding the idiosyncratic nature of adolescent communication, and the conversational and relational behaviours of young people (Chan, 2001; Noller, Feeney, & Peterson, 2001; Papini & Farmer, 1990; Rafaelli & Duckett, 1989; Readdick & Mullis, 1997; Rotenberg, 1995; Turkstra, 2001; Worcel et al., 1999; Young et al., 1999). It extends this research by identifying the specific conversational characteristics that young people use in helping conversations. The project confirmed the researcher's expectation that some counselling microskills currently used in training adolescent peer counsellors are not easy to use by adolescents and are considered by adolescents to be unhelpful. It also confirmed that some typical adolescent conversational helping behaviours which have been proscribed for use in other adolescent peer counsellor training programs are useful in adolescent peer counselling. The project conclusively demonstrated that the adolescent-friendly peer counsellor training program developed in the project overcame the difficulties of skill implementation identified in the adolescent peer counselling literature (Carr, 1984). The project identified for the first time the process used by adolescent peer counsellors to deal with issues related to role attribution and status difference. The current project contributes new information to the peer counselling literature through the discovery of important differences between early adolescent and late adolescent peer counsellors with regard to acquiring and mastering counselling skills, and their response to role attribution and status difference issues among their peers following counsellor training. As a result of the substantive findings the current project makes a significant contribution to social support theory and prosocial theory and to the adolescent peer counselling literature. It extends the range of prosocial behaviours addressed in published research by specifically examining the conversational helping behaviour of adolescents from a relational perspective. The current project provides new information that contributes to knowledge of social support in the form of conversational behaviour among adolescents identifying the interactive, collaborative, reciprocal and idiosyncratic nature of helping conversations in adolescents. Tindall (1989) suggests that peer counsellor trainers explore a variety of ways to approach a single training model that can augment and supplement the training process to meet specific group needs. The current project responded to this suggestion by investigating which counselling skills and behaviours adolescent peer counsellor trainees preferred, were easy to use by them, and were familiar to them, and then by using an intervention research process, devised a training program which incorporated these skills and behaviours into a typical adolescent helping conversation. A mixed method longitudinal design was used in an ecologically valid setting. The longitudinal nature of the design enabled statements about the process of the peer counsellors' experience to be made. The project combined qualitative and quantitative methods of data gathering. Qualitative data reflects the phenomenological experience of the adolescent peer counsellor and the researcher and quantitative data provides an additional platform from which to view the findings. The intervention research paradigm provided a developmental research method that is appropriate for practice research. The intervention research model is more flexible than conventional experimental designs, capitalises on the availability of small samples, accommodates the dynamism and variation in practice conditions and diverse populations, and explicitly values the insights of the researcher as a practitioner. The project combines intervention research with involvement of the researcher in the project thus enabling the researcher to view and report the findings through her own professional and practice lens.