Steps towards reducing high rates of tobacco use in remote Aboriginal communities

Robertson, Jan (2014) Steps towards reducing high rates of tobacco use in remote Aboriginal communities. Professional Doctorate (Research) thesis, James Cook University.

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Background: Tobacco use has been identified as a risk factor for six of the eight leading causes of death globally. In Australia the prevalence of tobacco smoking has more than halved over the last 30 years to around 15%. However, despite recent decreases, smoking rates of 41% (in 2012-2013) remain much higher among Australia's Indigenous peoples, with a disproportionately higher associated burden of disease. In small studies undertaken in remote communities over the last 25 years in the Top End of the Northern Territory, tobacco use has been consistently even higher with rates of up to 68%-83% among men and 65-73% among women. This includes remote Arnhem Land communities, where historical and cultural associations with tobacco use are diverse and long-standing.

Little is known regarding effective interventions to reduce smoking rates in remote settings such as these. The commonwealth government has made a commitment to close the life expectancy gap between Indigenous and non-Indigenous Australians by 2030, with unprecedented resources allocated to decrease the most common chronic disease risk factors, including tobacco smoking. The current ambitious target of halving the smoking rate among Indigenous Australians nationally by 2018 underlines the need to undertake tobacco research that can inform evidence-based action in a timely fashion through both effectiveness research and research dissemination.

Aim: The integrative research question posed by this thesis is: what strategies can work to reduce tobacco use in remote Aboriginal communities? The overall aim of the research reported in this thesis by publication is to inform policy implementation, clinical practice, community-driven interventions and future research efforts that will contribute to a reduction in the extraordinarily-high smoking rates found in remote Indigenous communities.

Methodology & Results: Data for the thesis are drawn from a five-year study, the Top End Tobacco Project (TETP) undertaken between 2007 and 2012 in three remote Aboriginal communities in the Arnhem Land region of the Northern Territory (NT). The candidate joined this study in the start-up phase and was therefore not involved in the study design. However, the candidate had a key role in project implementation including community engagement, data collection, data analysis and interpretation, and publication development.

The TETP aimed to implement and evaluate a multiple-component community tobacco intervention in selected communities. The six publications included in this thesis are based on data collected from the larger TETP study. Data sources included: qualitative and quantitative data collected concurrently during baseline community tobacco surveys; qualitative data collected through semi-structured interviews undertaken with key stakeholders across the NT; field trip notes taken during site visits to each of the participating communities and selected key policy documents.

The published papers include research reports on four sub-studies of the TETP (Papers #1,3, 4 & 5) and a discussion paper (Paper #2) and a literature review, which is currently under review (Paper #6). Multiple methodologies were used across the sub-studies and included qualitative and mixed-methods approaches.

Paper #1 reports a qualitative study which examined the perceptions of key stakeholders regarding the opportunities and challenges to translation of tobacco policy into practice in the setting of remote Aboriginal communities. Semi-structured interviews were undertaken in 2009-2010 with 82 key stakeholders in the study communities and regional centres across the Northern Territory. Major themes emerged regarding both opportunities and challenges. The highest opportunity area to reduce smoking was perceived to be implementation of 'smoke-free' policies.

Paper #2, also describes qualitative data drawn from both a pilot study previously undertaken in another part of Arnhem Land and that collected in the TETP. This paper considered strategies for remote area nurses to effectively engage with community members in order to reduce tobacco use. Public health and outreach approaches were considered to have the most promise.

Paper #3, reports data from the TETP community baseline tobacco surveys. A mixed method approach was utilised. The baseline data collected in 2008-9 (n=400 ≥16 years), showed that 76% of participants identified as current tobacco users. More than half of the current users were thinking about, or actively trying to quit. Data related to motivators to quitting and triggers to relapse were used to inform clinical interventions in remote primary health care settings.

Paper #4 reports the findings from case studies in which a critical realist approach was utilised in order to identify elements of effective management of environmental tobacco smoke (ETS) in remote communities. Consideration was given to the particular context of each example in order to make practical recommendations for similar locations. This study recommended adequately resourced "top-down, bottom-up" approach to the development and implementation of such policies.

Paper #5 provides further analysis of TETP baseline survey data in order to explore where, when and why survey participants restricted their smoking. The study concluded that household and workplace interventions targeting both men and women, and building on already accepted practices, were important strategies to reduce exposure to ETS.

Paper #6, a literature review, examined trends in the topics and types of indigenous tobacco research and associated outputs over the past decade. In order to further inform and expedite future research, policy development, health practice and community efforts, these outputs were also examined for evidence of alignment with identified research priorities and research translation strategies.

Preliminary analysis of the follow-up survey demonstrated very little change in smoking prevalence among the participants. Even so, more smokers were thinking about or actively trying to change their smoking, mostly by reducing daily consumption or lengthening periods of abstinence.

Discussion: Despite little change in prevalence over the five years of the TETP, community discourse on tobacco shifted well beyond that of 'humbugging', i.e. demand-sharing of tobacco, and cultural relationships with tobacco. At the close of the project, community members were discussing and acting on concerns about passive smoking. Interest in quitting or cutting down had increased. While there was clearly readiness for change in tobacco use at the individual level, the community environments where the research was undertaken provided little in the way of escape from constant exposure to tobacco smoke. This, coupled with limited quit support, challenged quit attempts.

However, the TETP demonstrated not only readiness, but also action, to extend smoke-free spaces across the participating communities in both public and private spaces. Analysis of the context and mechanisms at play with examples of observed community efforts to manage ETS, suggests that effective policy implementation may be achieved if these efforts are adequately resourced and there is local collaboration and ownership of the policies and/or implementation strategies.

Comprehensive local dissemination of the survey results contributed to raising the awareness of tobacco-related harms in an environment of many competing priorities. Although not included in the original study design, strategies to target tailored messages for identified knowledge users including decision makers were developed and refined throughout the study.

Summary of recommendations: Clinical interventions at the individual level would be improved by: the consistent inclusion and recording of brief tobacco interventions for all smokers attending clinics and the provision of more intense quit support. Active promotion of smoke-free spaces during the life of the project has been generally well-received, suggesting clinicians could advocate for a similar public health approach. These interventions are more likely to succeed if they are part of a range of concurrent community-based interventions. Despite a supportive policy environment at both the national and jurisdictional level, there appears to be a gap between policy development and implementation at the remote community level. Incorporating a 'top- down, bottom-up' approach in these populations, implementation strategies should acknowledge and integrate local cultural conventions. In small discrete communities, where high rates of tobacco use have been normalised, collection and comprehensive dissemination of local tobacco use data may improve the salience of messages regarding harmful effects, and contribute to a reduction in tobacco use. An increase in smoke-free spaces in communities with extraordinarily high rates of use will contribute to an environment that also encourages those changes. However, there is a need for adequate resourcing of community-level efforts to develop and effectively implement smoke-free policies and to bring equity of access to appropriate levels of quit support, including a wider range of cessation medications. Systematic use of research translation strategies integrated into evaluation study designs may contribute to an acceleration of uptake and use of new evidence by decision-makers seeking to reach targets to close the gap in life expectancy between Indigenous and non-Indigenous Australians.

Item ID: 45406
Item Type: Thesis (Professional Doctorate (Research))
Keywords: Aboriginal health, Aboriginal, Arnhem Land, Australia, clinical interventions, environmental tobacco smoke, general practitioners, Indigenous, interventions, Northern Territory, nurses, remote Aboriginal communities, remote communities, remote health, remote, smoke-free policies, smoking, tobacco use prevention, tobacco use, tobacco users, Top End Tobacco Project (TETP)
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Copyright Information: Copyright © 2014 Jan Robertson.
Additional Information:

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

Chapter 2: Robertson, Jan, Conigrave, Katherine M, Ivers, Rowena, Usher, Kim, and Clough, Alan R (2012) Translation of tobacco policy into practice in disadvantaged and marginalized subpopulations: a study of challenges and opportunities in remote Australian Indigenous communities. Health Research Policy and Systems, 10. p. 23.

Chapter 3: Robertson, Jan, Conigrave, Katherine, Ivers, Rowena, Hindmarsh, Elizabeth, and Clough, Alan (2013) Addressing high rates of smoking in remote Aboriginal communities: new evidence for GPs. Australian Family Physician, 42 (7). pp. 492-496.

Chapter 4: Robertson, Jan (2010) Tackling tobacco: a call to arms for remote area nurses. Contemporary Nurse, 37 (1). pp. 49-56.

Chapter 5: Robertson, Jan, Pointing, Boris Shane, Stevenson, Leah, and Clough, Alan R. (2013) "We made the rule, we have to stick to it": towards effective management of environmental tobacco smoke in remote Australian Aboriginal communities. International Journal of Environmental Research and Public Health, 10 (10). pp. 4944-4966.

Chapter 5: Stevenson, Leah C., Bohanna, India, Robertson, Jan A., and Clough, Alan R. (2013) Aboriginal people in remote communities in Arnhem Land (Northern Territory) restrict their smoking in some environments: implications for developing and implementing interventions to reduce exposure to environmental tobacco smoke. Drug and Alcohol Review, 32 (6). pp. 627-630.

Chapter 6: Robertson, Jan, Stevenson, Leah, Usher, Kim, Devine, Sue, and Clough, Alan (2015) A review of trends in indigenous Australian tobacco research (from 2004 to 2013), its associated outputs and evidence of research translation. Nicotine & Tobacco Research, 17 (8). pp. 1039-1048.

Date Deposited: 02 Feb 2017 02:16
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 > 920303 Aboriginal and Torres Strait Islander Health - Health System Performance (incl. Effectiveness of Interventions) @ 100%
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