The health worker smoking study: Indigenous health workers' personal use of tobacco and its impact on their ability to provide smoking cessation interventions

Thompson, Marlene (2013) The health worker smoking study: Indigenous health workers' personal use of tobacco and its impact on their ability to provide smoking cessation interventions. Masters (Research) thesis, James Cook University.

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Indigenous Health Workers (IHWs) are key members of the health care team delivering vital services to Indigenous communities throughout Australia. The IHW bridges the gap and often language barriers between the non-Indigenous health professional and the community. IHWs deliver a broad range of activities from primary health care, clinical care, health education, health promotion and community development. This important role extends from the generalist IHW to specific and specialized fields.

Tobacco is the leading most preventable health risk factor with smoking in Indigenous communities remaining significantly higher than in the non-Indigenous population. Smoking contributes to a higher level of the burden of disease and mortality in Indigenous Australians. Council of Australian Government (COAG) initiatives has seen a large injection of funding across the country with communities delivering various programs in an attempt to reduce the smoking rate in the Indigenous Australian population.

This project emerged from the results of the baseline survey of the Top End Tobacco Project (TETP) which was located in the three TETP study communities of Galiwin'ku, Gunbalyana and Ngukurr. I was employed as a Project Officer with James Cook University to implement the intervention components after the completion of the baseline survey. When discussing the results of the survey with the Chief Investigator, I became aware that community members, who had spoken about their smoking history, mentioned the clinic or doctor as providing them with information about addressing their smoking. There was no mention in any of the data that community members had received advice from an IHW. This concerned me. Given their pivotal role within the health team, my knowledge and experience as an Aboriginal Health Worker myself, I wondered why IHWs were not part of the provision of information. I spoke with two senior Health Workers from Galiwin'ku. Both thought research on IHW smoking needed to be explored. Both gave their blessings and encouraged me to undertake this study.

Smoking in IHWs has been discussed for a number of years. The literature review for this study, which was published in the Australian New Zealand Journal of Public Health and the Aboriginal and Islander Health Worker Journal, identified that smoking in IHWs has been discursive and descriptive, and that, if IHWs smoked themselves, it impeded their ability to carry out the requirements of their roles and provide tobacco information and cessation advice to the community. The review further identified that the available empirical evidence supporting this assertion was limited and patchy and included non-peer reviewed literature. The studies examined were assessed by utilizing an established approach to classifying Indigenous health research. This approach identified the perpetual discursive nature of the published and grey literature in addition to the continual descriptiveness of the available research. Additionally, the review identified a level of ambiguity as to who in fact was speaking about IHWs. Clarity was needed to ascertain the view of the IHWs. Thus the published literature review called for further research to identify IHWs' personal views and opinions relating to IHWs smoking and the delivery of tobacco interventions.

The literature review, uncovered the absence of the IHWs' voices, with the exception of a few small studies. This thesis is written from the standpoint of an Aboriginal woman who is also an Aboriginal Health Worker, committed to the foundations of Aboriginal community control. This project is one of self-determination, IHW self-articulation and a learning journey from this viewpoint bringing forth the voices of the IHWs and other participants. The key focus was the IHWs themselves. Their voices are pivotal in this study and are brought forward to ensure they are heard.

This study explored the challenges and opportunities of IHWs' smoking, the ways in which barriers to proving advice can be overcome and what needs to happen for them to address their own smoking. The majority of participants were IHWs from the three remote NT communities, but also involved were Indigenous and non-Indigenous health professional's familiar with the roles of IHWs in remote communities. The aim was to understand the impact of IHWs' smoking on the delivery of tobacco information and smoking interventions in these remote communities and to explore possible strategies to address any identified barriers.

This was a cross-sectional study using mixed methods. Semi structured individual interviews were conducted using a yarning approach with 43 health professionals. Quantitative data collected were basic demographic information related to the sample, smoking status and delivery of tobacco advice. The data was entered into Excel, transferred to SPSS and descriptive frequencies determined; significance was analyzed using Fishers Exact test, due to the small sample size. Qualitative results were analyzed by content analysis. Feedback to the communities and the participant's ensured analysis was interpreted in a way that was meaningful for the participants and best represented their opinions.

A total of 43 semi structured, individual interviews were conducted with 37.2% (n=16) IHWs, 34.9% (n=15) Allied Health Professionals, 14% (n=6) Registered Nurses, and 2.3% (n=1) Doctor. The sample included staff from the community controlled sector with 67% (n=29) and the government sector 32.6% (n= 14). Over half the sample 51.2% (n=22) were located in the three remote communities, with 58.1% (n=25) participants being Indigenous. Of the available IHWs in the three remote NT communities 67% participated, although absolute numbers were small (n=12). For the IHW 37.5% (n=6) were current smokers and 31.2% (n=5) former smokers. Current smoking status of the Indigenous participants overall 37.5% (n=9) in contrast to 5.6% (n=1) for the non-Indigenous participants. This difference was statistically significant (P=0.5).

The qualitative results add depth to understanding the issues encountered by IHWs. A content analysis identified five key themes with a further 23 sub themes. The five key themes were identified in response to specific questions were: Barriers to providing advice; Assisting IHWs to be comfortable in providing tobacco information and quit support; Support for IHWs to quit smoking; Providing information and education to the community; and Assisting IHWs to provide information more effectively. Each theme is presented throughout the thesis by participant's role as; IHW, Other Indigenous Participants and Non Indigenous Participants. The thesis themes are divided into these categories to clearly articulate the IHW voice and reduce the risk of ambiguity of responses with participants.

This study has shown that for IHWs in these communities, personal smoking impeded their ability to provide tobacco information or cessation advice. Overwhelmingly, 80% of IHWs confirmed this outcome. Additionally, other participants supported this view. The perception that IHWs should not smoke was articulated in this study. However, depending on the participant's knowledge, experience and personal views some judgments of IHWs appeared somewhat harsh.

IHW smoking and stress appears to be directly linked. Stress was both personal and professional. This conclusion is supported by the literature as well as in the data from this study. Given that IHWs are most likely community members themselves, working in their own communities increases their likelihood of burning out. Not addressing the stress increases the potential of IHW fatigue posing a risk to an already reducing workforce of highly skilled and qualified IHWs. The link between community and IHWs needs to be taken into account as community connectedness can be a double-edged sword. It can often assist with the delivery of health care, but critical incidents within the workplace can become highly personal. Given the local connection, when a death or major incident occurs, the IHWs more often than not are connected to the person through familial or other ways. This impact adds to an already strained workforce. This can manifest as stress and smoking can be one sign of this. The support of clinical supervision may assist with IHWs also addressing stress, grief and loss commonly found in Indigenous communities. Clinical supervision is part of the psychology and social work practice which is now also becoming part of the nursing profession, particularly in the mental health field. Given the current literature and evidence in this study, the connection with stress and smoking may be alleviated if workplace programs included clinical supervision for IHWs.

There are many benefits and incentives for employers to provide healthy lifestyle programs including tobacco cessation for their staff. Literature suggests smoking programs in the workplace improve the level of productivity in addition to a reduced level of sick leave through absenteeism. The costs associated with provision of such programs as opposed to the financial burden on employers through sick leave entitlements are self-evident. Therefore, smoking programs provided by the workplace would be an incentive to ensuring staff are well supported, healthier even if the harm minimization approach – cutting down with a view to quit - is available.

Before moving on to the recommendations from this study I want to discuss the concept of publishing papers, reports or research outputs in two or more formats (i.e., in parallel) with the purpose of reaching a broader audience to ensure the work is accessible to all. I have coined this concept as parallel publishing which supports knowledge translation of research practice. Ensuring praxis and good scientific practice, this term is used to describe a method or a process that may assist other Indigenous researchers or others from non-English speaking backgrounds when describing their approach or methodology in terms of dissemination of research findings. In Indigenous health this is particularly important to ensure that communities and their IHWs are included. An illustration is that the literature review was published as an academic document in the Australian and New Zealand Journal of Public Health and using modified language in the Aboriginal Islander Health Worker Journal. The first publication informs the academic community and mainstream decision makers; the second publication communicates to IHWs and community members.

The act of parallel publishing has been practiced for over a hundred years from the early 1900s to the present day as a method of reaching broader audiences. However, it has not been defined nor characterized. "Parallel publishing" is a new concept and one that has been developed and reflected upon throughout this study and importantly it warrants further investigation and development.

Recommendations from this study include:

1. Undertake further research:

a. To understand the underlying stressors IHWs experience in their personal and professional lives which may inhibit them from quitting smoking;

b. To develop appropriate, holistic and comprehensive workplace tobacco programs for IHWs and other staff;

c. To evaluate the impacts and outcomes of these programs on IHWs and whether there is a flow on affect to the community in which they work.

2. For employers to implement holistic and comprehensive smoking programs for staff with the following components:

a. Access to pharmacotherapy's and other treatment modalities funded by employers;

b. Personalized in person support to quit smoking;

c. Access to group programs and support (where appropriate);

d. Incorporate stress management as part of the program.

3. To incorporate tobacco units of competencies into all IHW training, becoming a core unit from Certificate IV lever or higher.

4. For employers provide clinical supervision for IHWs to assist with stress management, as support to alleviate and prevent IHW burn out.

Item ID: 43747
Item Type: Thesis (Masters (Research))
Keywords: Aboriginal health workers; cigarette smoking; health care workers; healthcare workers; IHWs; Indigenous Health Workers; nicotine addiction; quit smoking; quitting smoking; smoking cessation; smoking; stop smoking; stress management; TETP; tobacco smoking; Top End Tobacco Project; Torres Strait Islander health workers
Related URLs:
Copyright Information: Copyright © 2013 Marlene Thompson.
Additional Information:

Publications arising from this thesis are available from the Related URLs field. The publications are:

Chapter 2: Thompson, Marlene, Robertson, Jan, and Clough, Alan (2011) A review of the barriers preventing Indigenous health workers delivering tobacco interventions to their communities. Australian and New Zealand Journal of Public Health, 35 (1). pp. 47-53.

Chapter 2: Thompson, Marlene A. (2010) What are Indigenous health workers saying about their smoking status: does it prevent them providing tobacco information and/or quit support to the community? Aboriginal and Islander Health Worker Journal, 34 (2). pp. 3-5.

Chapter 6: Thompson, Marlene (2011) The best bang for our buck: recommendations for the provision of training for tobacco action workers and Indigenous health workers. Contemporary Nurse, 37 (1). pp. 90-91.

Date Deposited: 18 May 2016 04:52
FoR Codes: 11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111701 Aboriginal and Torres Strait Islander Health @ 100%
SEO Codes: 92 HEALTH > 9203 Indigenous Health > 920301 Aboriginal and Torres Strait Islander Health - Determinants of Health @ 50%
92 HEALTH > 9203 Indigenous Health > 920302 Aboriginal and Torres Strait Islander Health - Health Status and Outcomes @ 50%
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