Aboriginal health workers experience multilevel barriers to quitting smoking: a qualitative study

Exploring self-determined solutions to service and system challenges to promote social and emotional wellbeing in Aboriginal and Torres Strait Islander people: a qualitative study

Introduction

Many Aboriginal and Torres Strait Islander people living on Kaurna Country in northern Adelaide experience adverse health and social circumstances. The Taingiwilta Pirku Kawantila study sought to understand challenges facing Aboriginal and Torres Strait Islander communities and identify solutions for the health and social service system to promote social and emotional wellbeing.

Methods

This qualitative study applied Indigenous methodologies undertaken with Aboriginal and Torres Strait Islander governance and leadership. A respected local Aboriginal person engaged with Aboriginal and Torres Strait Islander community members and service providers through semi-structured interviews and yarning circles that explored community needs and challenges, service gaps, access barriers, success stories, proposed strategies to address service and system challenges, and principles and values for service design. A content analysis identified the breadth of challenges in addition to describing key targets to empower and connect communities and optimize health and social services to strengthen individual and collective social and emotional wellbeing.

Results

Eighty-three participants contributed to interviews and yarning circles including 17 Aboriginal community members, 38 Aboriginal and Torres Strait Islander service providers, and 28 non-Indigenous service providers. They expressed the need for codesigned, strengths-based, accessible and flexible services delivered by Aboriginal and Torres Strait Islander workers with lived experience employed in organisations with Aboriginal and Torres Strait Islander leadership and governance. Community hubs and cultural events in addition to one-stop-shop service centres and pre-crisis mental health, drug and alcohol and homelessness services were among many strategies identified.

Conclusion

Holistic approaches to the promotion of social and emotional wellbeing are critical. Aboriginal and Torres Strait Islander people are calling for places in the community to connect and practice culture. They seek culturally safe systems that enable equitable access to and navigation of health and social services. Aboriginal and Torres Strait Islander workforce leading engagement with clients is seen to safeguard against judgement and discrimination, rebuild community trust in the service system and promote streamlined access to crucial services.

Impact of an Aboriginal and Torres Strait Islander brief intervention training program on health staff participants' own health behaviours: smoking, nutrition and physical activity

ISSUE

Little research has been conducted on the impact of Aboriginal and Torres Strait Islander brief intervention training programs on health staff participants' own health behaviours. Through the Queensland B.strong program (2017-2020), brief intervention training in smoking cessation, nutrition and physical activity was provided to the Aboriginal and Torres Strait Islander health workforce and other health and community professionals. This study examined the program's impact on participants' own health behaviours.

METHODS

Data were collected through four surveys (pre-and post-training workshop, and 3-month and 6-month follow-up) of the 1,131 participants in B.strong training workshops from June 2017 to August 2019. Surveys included items on participants' own health behaviours. Pre- and post-workshop surveys were paper-based, and follow-up surveys were completed online. For the analysis of data reported in this paper, paired-samples t-tests were used to assess changes between pre-workshop and 3-month follow-up.

RESULTS

Statistically significant improvements were found between pre-workshop and 3-month follow-up in the number of serves of vegetables or legumes/beans eaten per day, the number of serves of fruit eaten per day, and in time spent in physical activity. However, there was: no statistically significant change in smoking status, with baseline rates being relatively low; a statistically significant increase in consumption of sugary drinks, and of take-away foods; a non-significant increase in consumption of snack foods; and no significant change in sedentary behaviour of participants.

CONCLUSION

While some positive changes in participants' own health behaviours in nutrition and physical activity were associated with the B.strong program, there was no change in their smoking behaviour.

SO WHAT

This study found that some improvements in participants' own health behaviours were associated with the B.strong program. This research may inform future Indigenous brief intervention training programs and health services on how to promote healthy behaviours for health staff themselves.

Influence of Personal, Environmental, and Community Factors on Cigarette Smoking in Adolescents: A Population-Based Study from Taiwan

Understanding the factors that influence cigarette smoking among adolescents is critical. We identified personal, community, and environmental factors associated with current cigarette smoking among adolescents. This population-based cross-sectional analysis study was conducted using the 2012 Taiwan Global Youth Tobacco Survey and the sociodemographic statistics of the city or county from Taiwan’s Ministry of the Interior. A total of 27,524 participants (age: 12–18-years) was included. The associated factors were identified through logistic regression. A path analysis was performed to examine the pathway from the associated factors to current cigarette smoking. According to this analysis, the following factors were prominently and positively associated with adolescent cigarette smoking: one personal factor (pocket money), five environmental factors (home secondhand smoke (SHS) exposure, smoker friends, outside SHS exposure, school SHS exposure, and smoker parents), and two community factors (free cigarettes from tobacco companies and indigenous population). By contrast, five personal factors (feeling less comfortable smoking at social occasions, feeling indifferent about smoking or not smoking at social occasions, female sex, feeling that quitting is difficult, and feeling that quitting after having smoked is harmful to health) and one environmental factor (school antismoking education) had negative effects. Thus, comprehensive interventions promoting the perception of harm caused by smoking and interrupting access to cigarettes through social networks can reduce cigarette smoking in adolescents.

Prioritizing Built Environmental Factors to Tackle Chronic and Infectious Diseases in Remote Northern Territory (NT) Communities of Australia: A Concept Mapping Study

High prevalence of chronic and infectious diseases in Indigenous populations is a major public health concern both in global and Australian contexts. Limited research has examined the role of built environments in relation to Indigenous health in remote Australia. This study engaged stakeholders to understand their perceptions of the influence of built environmental factors on chronic and infectious diseases in remote Northern Territory (NT) communities. A preliminary set of 1120 built environmental indicators were systematically identified and classified using an Indigenous Indicator Classification System. The public and environmental health workforce was engaged to consolidate the classified indicators (n = 84), and then sort and rate the consolidated indicators based on their experience with living and working in remote NT communities. Sorting of the indicators resulted in a concept map with nine built environmental domains. Essential services and Facilities for health/safety were the highest ranked domains for both chronic and infectious diseases. Within these domains, adequate housing infrastructure, water supply, drainage system, reliable sewerage and power infrastructure, and access to health services were identified as the most important contributors to the development of these diseases. The findings highlight the features of community environments amenable to public health and social policy actions that could be targeted to help reduce prevalence of chronic and infectious diseases.

An ecological model of drug and alcohol use and related harms among Aboriginal and Torres Strait Islander Australians: A systematic review of the literature

Globally, Indigenous populations experience a disproportionately higher burden of disease related to substance use. Effective prevention of harm related to substance use is a key strategy for improving the health and wellbeing of Aboriginal and Torres Strait Islander peoples in Australia. To inform preventative approaches, this review synthesised the evidence of risk and protective factors of substance use and related harms among Aboriginal and Torres Strait Islander peoples. Eight peer-reviewed and two grey literature databases were systematically searched for quantitative or qualitative studies assessing factors associated with substance use and related harms among Aboriginal and Torres Strait Islander peoples, published between 1 January 1990 and 30 April 2018. Study quality was assessed using validated instruments. Risk or odds ratios were extracted or calculated and factors were summarised in an ecological model into individual, relationship, community, societal or culturally-distinct levels. Thirty-eight relevant studies were identified and reviewed. Individual-level risk factors for substance use were identified including low socio-economic status, high psychological distress, poly drug use and being male. Relationship-level factors were peer pressure and partner/family substance use; protective factors were supportive environments and positive role models. Community-level risk factors included availability of substances. Culturally-distinct factors included cultural connection as a protective factor, but cultural obligations around sharing was a risk factor. Societal risk factors included intergenerational trauma caused by government policies. These findings highlight the importance of tailored preventative approaches for Aboriginal and Torres Strait Islander communities that address identified risk factors and promote protective factors across all ecological levels.

Beyond the pipeline: a critique of the discourse surrounding the development of an Indigenous primary healthcare workforce in Australia

A central strategy in addressing health disparities experienced by Indigenous people has been based on a concern with workforce improvement. In this paper, the Indigenous Australian healthcare workforce literature since 1977 is reviewed and its scope of concern, as being often limited to questions of 'supply', is critiqued. The pipeline metaphor, whether used explicitly or implied, regularly focuses attention on closing the gap on Indigenous representation within the health workforce. The exception though is the discourse concerning Indigenous Health Workers (IHWs), where questions concerning the legitimacy of the role continue to abound within a workforce hierarchy where community knowledge, though shown to be crucial to culturally safe health service provision, is trumped by the other health professions whose knowledges and legitimacy are not in question. This contrast exemplifies the need to examine the working of power not just 'supply'. The pipeline metaphor is disrupted with concerns about a range of other 'gaps' - gaps in the recognition of Indigenous knowledges, in organisational structures, in governance and in self-awareness by the health professions of their whiteness. As the health system continues to measure workforce development in terms of pipeline capacity, our study questions what happens beyond the pipeline.

Process evaluation of the Getting it Right study and acceptability and feasibility of screening for depression with the aPHQ-9

Background

The Getting it Right study determined the validity, sensitivity, specificity and acceptability of the culturally adapted 9-item Patient Health Questionnaire (aPHQ-9) as a screening tool for depression in Aboriginal and Torres Strait Islander (hereafter referred to as Indigenous) people. In this process evaluation we aimed to explore staff perceptions about whether Getting it Right was conducted per protocol, and if the aPHQ-9 was considered an acceptable and feasible screening tool for depression in primary healthcare. This process evaluation will provide information for clinicians and policy makers about the experiences of staff and patients with Getting it Right and what they thought about using the aPHQ-9.

Methods

Process evaluation using grounded theory approaches. Semi-structured interviews with primary healthcare staff from services participating in Getting it Right were triangulated with feedback (free-text and elicited) from participants collected during the validation study and field notes. Data were thematically analysed according to the Getting it Right study protocol to identify the acceptability and feasibility of the aPHQ-9.

Results

Primary healthcare staff (n = 36) and community members (n = 4) from nine of the ten participating Getting it Right services and Indigenous participants (n = 500) from the ten services that took part. Most staff reported that the research was conducted according to the study protocol. Staff from two services reported sometimes recruiting opportunistically (rather than recruiting consecutive patients attending the service as outlined in the main study protocol), when they spoke to patients who they knew from previous interactions, because they perceived their previous relationship may increase the likelihood of patients participating. All Getting it Right participants responded to at least six of the seven feedback questions and 20% provided free-text feedback. Most staff said they would use the aPHQ-9 and most participants said that the questions were easy to understand (87%), the response categories made sense (89%) and that they felt comfortable answering the questions (91%).

Conclusion

Getting it Right was predominantly conducted according to the study protocol. The aPHQ-9, the first culturally adapted, nationally validated, freely available depression screening tool for use by Indigenous people, appears to be acceptable and feasible to use.

Trial registration

Australian New Zealand Clinical Trial Registry ANZCTR12614000705684, 03/07/2014.

[The prevalence of strategies for cessation of tobacco use in primary health care: an integrative review]

The habit of tobacco use/smoking, which is a major concern of Primary Health Care (PHC), is a serious public health problem and the main avoidable cause of death in the world. The relevance of actions, whose focus is to facilitate the cessation of this habit, motivates the discussion of studies that have different approaches to tackle this issue by seeking to train PHC professionals accordingly. A search was conducted in the Lilacs, MEDLINE and Web of Science databases for recent scientific publications (2010-2015). The key words were combined with Boolean operators and, after analysis of the articles found, 75 are discussed in this article since they have strategies with a higher prevalence in PHC. The conclusion drawn is that the brief or intense individual approach using the 5A method (Transtheoretical Model) is the most widely adopted, as well as bupropion and nicotine replacement patches. The increasing use of hard technology requires new studies that examine their impact on the treatment of smokers. It was clearly revealed that there is a need for health professionals to be better prepared to address the issue with the users, in addition to a lack of stimulus and proper conditions to work in the PHC team directly reflecting scientific advances in clinical practice.

"We are everything to everyone": a systematic review of factors influencing the accountability relationships of Aboriginal and Torres Strait Islander health workers (AHWs) in the Australian health system

BACKGROUND

Health policy in Australia positions Aboriginal and Torres Strait Islander Health Workers (AHWs) as central to improving Aboriginal and Torres Strait Islander peoples' health, with high expectations of their contribution to closing the gap between Indigenous and non-Indigenous health outcomes. Understanding how AHWs' governance and accountability relationships influence their ability to address such health inequities has policy, programme and ethical significance. We sought to map the evidence of AHWs' experiences of accountability in the Australian health system.

METHODS

We followed an adapted qualitative systematic review process to map evidence on accountability relations in the published literature. We sought empirical studies or first-person accounts describing AHWs' experiences of working in government or Aboriginal community-controlled services anywhere in Australia. Findings were organised according to van Belle and Mayhew's four dimensions of accountability - social, political, provider and organisational.

RESULTS

Of 27 included studies, none had a primary focus on AHW governance or AHWs' accountability relationships. Nonetheless, selected articles provided some insight into AHWs' experiences of accountability across van Belle and Mayhew's four dimensions. In the social dimension, AHWs' sense of connection and belonging to community was reflected in the importance placed on AHWs' cultural brokerage and advocacy functions. But social and cultural obligations overlapped and sometimes clashed with organisational and provider-related accountabilities. AHWs described having to straddle cultural obligations (e.g. related to gender, age and kinship) alongside the expectations of non-Indigenous colleagues and supervisors which were underpinned by 'Western' models of clinical governance and management. Lack of role-clarity stemming from weakly constituted (state-based) career structures was linked to a system-wide misunderstanding of AHWs' roles and responsibilities - particularly the cultural components - acting as a barrier to AHWs working to their full capacity for the benefit of patients, broader society and their own professional satisfaction.

CONCLUSIONS

In literature spanning different geographies, service domains and several decades, this review found evidence of complexity in AHWs' accountability relationships that both affects individual and team performance. However, theoretically informed and systematic investigation of accountability relationships and related issues, including the power dynamics that underpin AHW governance and performance in often diverse settings, remains limited and more work in this area is required.

Experiences of young smokers in quitting smoking in twin cities of Pakistan: a phenomenological study

BACKGROUND

Smoking is highly prevalent in Pakistan claiming the lives of over 100,000 individuals every year. A significant proportion of smokers (24.7%) make an attempt to quit each year but 97.4% fail to quit successfully. Little is known about the reasons for, and experiences of, failed quit attempts. This study was carried out to explore the experiences of young male smokers in quitting smoking in the twin cities of Pakistan METHOD: A qualitative study was carried out using a phenomenological approach in Rawalpindi and Islamabad. A total of 11 participants were interviewed. All study participants were male and had made at least one quit attempt. Study participants were a mix of smokers who failed to quit smoking, intermittent smokers and successful quitters. Streubert's (1991) method of phenomenology was followed during data analysis.

RESULTS

The experiences of smokers while smoking "the smoking phase" have major effects on their journey towards quitting smoking. The smoking phase consists of three major stages: contact with initial smoking stimuli, the journey from first puff to enjoying smoking and then finally smoking becoming part of life. However, the journey towards quitting smoking is not as simple as the journey towards becoming a smoker. Instead, smokers get trapped in three overlapping cycles of smoking and quit attempts: smoking & forced quitting, smoking & intentional quitting, and smoking & intermittent smoking before successful quitting. Breaking the cycle is not easy in the presence of trapping factors (addiction, high availability, easy affordability, conducive social setup and low perceived risks of smoking). Three factors play a major role in breaking these cycles which are strong will power, continuous peer support and avoidance of smokers' company.

CONCLUSION

A young smoker, during his experience of quitting smoking gets entrapped in several overlapping cycles of smoking & quit attempts before successful quitting. There are known entrapping factors as well as factors which help in breaking these cycles. Targeted interventions are needed to facilitate smoking cessation among young smokers in Pakistan.

Barriers to Quitting Smoking Among Young Adults: The Role of Socioeconomic Status

PURPOSE

The aims of this analysis were to explore how self-reported barriers to quitting vary by socioeconomic status (SES) among young-adult smokers and to assess their relationship to quitting.

DESIGN

This analysis uses 2 waves of telephone-survey data from the Minnesota Adolescent Community Cohort study.

SETTING

Midwestern United States.

PARTICIPANTS

Participants (n = 419) were smokers aged 17 to 24 years.

MEASURES

Socioeconomic status was estimated using the highest level of education completed by the participants' parents. Demographics, smoking behavior, and perceived barriers to quitting were collected via survey questions.

ANALYSIS

Differences in barriers by SES were assessed using prevalence ratios (PRs). Relative risks were calculated to assess the association between barriers and quitting status 1 year later, testing for effect modification by SES.

RESULTS

Compared to the high SES group (n = 314), the low SES group (n = 105) was more likely to report several barriers to quitting; however, only the risk of gaining weight was significantly more common (PR: 1.38 [1.05-1.83]). There were no significant associations between barriers and quitting status 1 year later, but the number of cigarettes per day was consistently related to the likelihood of quitting 1 year later, regardless of SES.

CONCLUSION

Despite the limited generalizability to racially diverse populations and different geographic locations, the results suggest perceived barriers may not differ by SES or predict quitting among young adults; however, nicotine dependence may play an important role.

Process evaluation of a primary healthcare validation study of a culturally adapted depression screening tool for use by Aboriginal and Torres Strait Islander people: study protocol

INTRODUCTION

Process evaluations are conducted alongside research projects to identify the context, impact and consequences of research, determine whether it was conducted per protocol and to understand how, why and for whom an intervention is effective. We present a process evaluation protocol for the Getting it Right research project, which aims to determine validity of a culturally adapted depression screening tool for use by Aboriginal and Torres Strait Islander people. In this process evaluation, we aim to: (1) explore the context, impact and consequences of conducting Getting It Right, (2) explore primary healthcare staff and community representatives' experiences with the research project, (3) determine if it was conducted per protocol and (4) explore experiences with the depression screening tool, including perceptions about how it could be implemented into practice (if found to be valid). We also describe the partnerships established to conduct this process evaluation and how the national Values and Ethics: Guidelines for Ethical Conduct in Aboriginal and Torres Strait Islander Health Research is met.

METHODS AND ANALYSIS

Realist and grounded theory approaches are used. Qualitative data include semistructured interviews with primary healthcare staff and community representatives involved with Getting it Right. Iterative data collection and analysis will inform a coding framework. Interviews will continue until saturation of themes is reached, or all participants are considered. Data will be triangulated against administrative data and patient feedback. An Aboriginal and Torres Strait Islander Advisory Group guides this research. Researchers will be blinded from validation data outcomes for as long as is feasible.

ETHICS AND DISSEMINATION

The University of Sydney Human Research Ethics Committee, Aboriginal Health and Medical Research Council of New South Wales and six state ethics committees have approved this research. Findings will be submitted to academic journals and presented at conferences.

TRIAL REGISTRATION NUMBER

ACTRN12614000705684.

The physical health of Indigenous and non-Indigenous patients participating in residential rehabilitation programs: a comparison study

OBJECTIVE

To examine the differences in the physical health of Indigenous and non-Indigenous patients with severe mental illness (SMI) undergoing psychiatric rehabilitation.

METHODS

An audit of the physical health of patients ( n = 361) in all publicly funded residential rehabilitation programs in Queensland was carried out in late 2014. Data collection focused on clinical and lifestyle factors associated with physical health.

RESULTS

The prevalence of smoking, substance use and type 2 diabetes in Indigenous patients was significantly higher than rates found in non-Indigenous patients. Metabolic syndrome was also significantly higher in indigenous patients, with 66% of Indigenous patients compared to 46% of non-Indigenous patients meeting criteria for metabolic syndrome.

CONCLUSIONS

Patients with SMI in residential rehabilitation programs have poor physical health. Our findings underscore the need for clinicians to develop and evaluate interventions aimed at improving the metabolic profile of those with SMI in residential rehabilitation programs. Historical factors and cultural traditions need to be considered when designing lifestyle interventions for Indigenous patients.

Improvement in Depressive Symptoms Among Hispanic/Latinos Receiving a Culturally Tailored IMPACT and Problem-Solving Intervention in a Community Health Center

The present study investigated whether a culturally-tailored problem-solving intervention delivered by a trained depression care specialist (DCS) would improve depressive symptoms over a 6 month period among Hispanic/Latino patients in a federally-qualified community health center by the California-Mexico border. Participants included 189 low income Hispanic/Latino patients of Mexican heritage. Based on the improving mood-promoting access to collaborative treatment (IMPACT) evidence-based treatment, patients received evidence-based problem-solving therapy. The Patient Health Questionnaire-9 (PHQ-9) was administered to assess changes in self-reported depressive symptoms between baseline and monthly for a 6-month follow up period. The majority of participants were female (72.5%) with a mean age of 52.5 (SD = 11.7). The mean PHQ-9 at baseline was 16.9 (SD = 4.0) and at the 6-month follow-up, the average PHQ-9 decreased to 9.9 (SD = 5.7). A linear mixed model analysis showed significant improvement in PHQ-9 scores over a 6 month period (F = 124.1; p < 0.001) after controlling for age, gender, smoking and diabetes. There was a significant three way interaction between time, gender and smoking (p = 0.01) showing that the depressive symptoms among male smokers did not improve as much as non-smoking males and females. Results suggest that a culturally-tailored problem solving approach can significantly reduce depressive symptoms among Hispanic/Latino low-income patients.

Assessing beliefs and risk perceptions on smoking and smoking cessation in immigrant Chinese adult smokers residing in Vancouver, Canada: a cross-sectional study

OBJECTIVES

We aimed to conduct culturally-based participatory research to assess cultural and belief contexts for smoking behaviours within Mandarin and Cantonese communities. Outcome variables were smoking-related knowledge, smoking patterns, attitudes and beliefs, and perceived barriers and facilitators to successful cessation.

DESIGN

A community-based approach was applied involving smokers, community key-informants and professionals in study design and implementation. Initially, focus groups were conducted and findings were used to develop study instrument. Participants responded once to study questionnaire after informed consent.

SETTING

Community based in the Greater Vancouver Area, Canada.

PARTICIPANTS

16 Chinese smokers participated in focus groups and subsequently, 167 current Chinese immigrant (137 males and 30 females) smokers from Mandarin and Cantonese communities, recruited with the help of community agencies and collaborating physicians, were enrolled in a cross-sectional study.

RESULTS

We found that a majority believed smoking was harmful on their health. Younger smokers (<35 years of age) did not mind smoking in front of young children compared to older smokers (≥35 years of age) (p<0.001). People with high school or lower levels of education believed that they would benefit more from smoking than suffering from withdrawal symptoms compared to better educated smokers (p<0.05). Mandarin smokers were significantly more likely to encourage others to quit than Cantonese smokers (p<0.05). Many indicated not receiving adequate support from care providers and lack of access to culturally and linguistically appropriate cessation programmes impacted on their ability to quit smoking.

CONCLUSIONS

Our study highlighted the importance of tobacco beliefs and perceptions among Mandarin and Cantonese speaking immigrants with limited access to healthcare information and for younger smokers whose attention to health consequences of smoking may be limited as well. Study participants were generally aware of the health risks and were willing to quit. Access to appropriate cessation programmes would fulfil their willingness.

Tobacco use among urban Aboriginal Australian young people: a qualitative study of reasons for smoking, barriers to cessation and motivators for smoking cessation

Smoking prevalence among Aboriginal Australian young people greatly exceeds the prevalence in the broader population of Australian young people, yet limited research has explored the social context in which young Aboriginal Australians smoke. Four focus groups were conducted in 2009 with South Australian Aboriginal smokers aged 15–29 years residing in urban areas (n = 32) to examine attitudes and experiences surrounding smoking and quitting. The primary reasons for smoking initiation and maintenance among Aboriginal Australian young people were identified as stress, social influence and boredom. Motivators for quitting were identified as pregnancy and/or children, sporting performance (males only), cost issues and, to a lesser extent, health reasons. The barriers to cessation were identified as social influence, the perception of quitting as a distant event and reluctance to access cessation support. However, it appears that social influences and stress were particularly salient contributors to smoking maintenance among Aboriginal Australian young people. Smoking cessation interventions targeted at young urban Aboriginal Australian smokers should aim to build motivation to quit by utilising the motivators of pregnancy and/or children, sporting performance (males only), cost issues and, to a lesser extent, health reasons, while acknowledging the pertinent role of social influence and stress in the lives of young urban Aboriginal Australian smokers.

Perceived barriers to smoking cessation in selected vulnerable groups: a systematic review of the qualitative and quantitative literature

OBJECTIVES

To identify barriers that are common and unique to six selected vulnerable groups: low socioeconomic status; Indigenous; mental illness and substance abuse; homeless; prisoners; and at-risk youth.

DESIGN

A systematic review was carried out to identify the perceived barriers to smoking cessation within six vulnerable groups.

DATA SOURCES

MEDLINE, EMBASE, CINAHL and PsycInfo were searched using keywords and MeSH terms from each database's inception published prior to March 2014.

STUDY SELECTION

Studies that provided either qualitative or quantitative (ie, longitudinal, cross-sectional or cohort surveys) descriptions of self-reported perceived barriers to quitting smoking in one of the six aforementioned vulnerable groups were included.

DATA EXTRACTION

Two authors independently assessed studies for inclusion and extracted data.

RESULTS

65 eligible papers were identified: 24 with low socioeconomic groups, 16 with Indigenous groups, 18 involving people with a mental illness, 3 with homeless groups, 2 involving prisoners and 1 involving at-risk youth. One study identified was carried out with participants who were homeless and addicted to alcohol and/or other drugs. Barriers common to all vulnerable groups included: smoking for stress management, lack of support from health and other service providers, and the high prevalence and acceptability of smoking in vulnerable communities. Unique barriers were identified for people with a mental illness (eg, maintenance of mental health), Indigenous groups (eg, cultural and historical norms), prisoners (eg, living conditions), people who are homeless (eg, competing priorities) and at-risk youth (eg, high accessibility of tobacco).

CONCLUSIONS

Vulnerable groups experience common barriers to smoking cessation, in addition to barriers that are unique to specific vulnerable groups. Individual-level, community-level and social network-level interventions are priority areas for future smoking cessation interventions within vulnerable groups.

TRIAL REGISTRATION NUMBER

A protocol for this review has been registered with PROSPERO International Prospective Register of Systematic Reviews (Identifier: CRD42013005761).

Smoking behavior among nurses in rural Greece

Evidence suggests that rural health care providers may be at increased risk for tobacco addiction. Few researchers have studied the habitual use of tobacco in rural Greece and no published studies have examined sustained tobacco use by nurses working in these areas or their knowledge and attitudes toward smoking cessation. To explore the above, the authors conducted a questionnaire-based study in 40 health centers in rural mainland and island Greece. Two hundred twenty nurses were surveyed (65% response rate). Thirty-two percent of the nurse respondents were smokers, 54% were non-smokers, and 14% were former smokers. Only 8% of respondents had been trained to assist clients with smoking cessation.

Personal and social determinants sustaining smoking practices in rural China: a qualitative study

Introduction

Tobacco use in China is disproportionally distributed among rural and urban populations with rural people smoking more. While there is a wealth of evidence on the association between tobacco use among rural people and their lower socio-economic status (SES), how social structural factors contribute to rural smoking is not well understood. Guided by a socio-ecological model, the objective of this study was to explore the personal and social determinants that play a key role in sustaining smoking practices among Chinese rural people.

Methods

An ethnographic study was conducted in a rural area of Central Jiangsu, China. Participants (n = 29) were recruited from families where there was at least one smoking resident and there were young children. In-depth interviews and unstructured observations were used to collect data, which were then analyzed with an interpretive lens.

Results

Although individuals had limited knowledge about the risks of smoking and lack of motivation to quit, social factors were in effect the main barriers to quitting smoking. Cigarette exchange and cigarette gifting permeated every aspect of rural family life, from economic activities to leisure pastimes, in family and wider social interactions. Traditional familism and collectivism interplayed with the pro-smoking environment and supported rural people’s smoking practices at the community level. Living in the rural area was also a barrier to quitting smoking because of the lack of information on smoking cessation and the influence of courtyard-based leisure activities that facilitated smoking.

Conclusion

Development of comprehensive smoking cessation interventions in rural China needs to extend beyond an individual level to take into account the social determinants influencing smoking practices.