"We made the rule, we have to stick to it": towards effective management of environmental tobacco smoke in remote Australian Aboriginal communities

Methods in realist evaluation: A mapping review

Realist evaluation is becoming increasingly popular as an evaluation methodology. Its main objective is to uncover the mechanisms that lead to observed outcomes following an intervention and the contextual conditions that enabled this. The focus is on explaining why, for whom and in what circumstances an intervention works. It is a theory-driven approach and is explicitly method neutral, meaning that both quantitative and qualitative data collection methods can be used to unearth the underlying mechanisms that cause the intervention outcomes. In this review, we aim to map the methods used in realist evaluation studies, to draw lessons from the findings and to reflect on ways forward. We found that qualitative methods and interviews specifically are most commonly used in realist evaluations; that theory is often absent behind the methods and sampling techniques used; and that more innovative methods remain underexplored. We conclude the review by proposing four ways forward: (1) developing realist surveys, (2) exploring the relevance of innovative methods, (3) increasing the attention paid to sampling procedures and (4) strengthening the theory-driven nature of method. We believe that these four action points can strengthen the practice of realist evaluation and its outcomes.

Exploring the Reported Strengths and Limitations of Aboriginal and Torres Strait Islander Health Research: A Narrative Review of Intervention Studies

High quality intervention research is needed to inform evidence-based practice and policy for Aboriginal and Torres Strait Islander communities. We searched for studies published from 2008-2020 in the PubMed database. A narrative review of intervention literature was conducted, where we identified researcher reported strengths and limitations of their research practice. A total of 240 studies met inclusion criteria which were categorised as evaluations, trials, pilot interventions or implementation studies. Reported strengths included community engagement and partnerships; sample qualities; Aboriginal and Torres Strait Islander involvement in research; culturally appropriate and safe research practice; capacity building efforts; providing resources or reducing costs for services and communities; understanding local culture and context; and appropriate timelines for completion. Reported limitations included difficulties achieving the target sample size; inadequate time; insufficient funding and resources; limited capacity of health workers and services; and inadequate community involvement and communication issues. This review highlights that community consultation and leadership coupled with appropriate time and funding, enables Aboriginal and Torres Strait Islander health intervention research to be conducted. These factors can enable effective intervention research, and consequently can help improve health and wellbeing outcomes for Aboriginal and Torres Strait Islander people.

Engaging with Aboriginal Shire Councils in remote Cape York communities to address smoke-free environments

The high prevalence and health effect of tobacco smoking and secondhand smoke exposure among Aboriginal and Torres Strait Islander people is well known. Due to its significance, the responsibility of tackling smoking among Aboriginal and Torres Strait Islander people should not remain solely with health service providers. The creation of supportive environments and collaboration beyond the health sector are critical elements of comprehensive primary health care practised by Aboriginal Community Controlled Health Services. This paper discusses how Apunipima Cape York Health Council worked with three Aboriginal Shire Councils to create more smoke-free places, using local working groups, information sessions and community-based health promotion. The flexibility and the time allocated to the engagement process with councils, community leaders, organisations and community members were important. All three communities acknowledged the benefits of role modelling and working together to improve health, with addressing tobacco smoking seen as 'everyone's business' and 'not just service providers'. Aboriginal Shire Councils can play a critical role, in partnership with Aboriginal Community Controlled Health Services, in creating healthy places that enable healthy choices.

Interventions to encourage smoke-free homes in remote indigenous Australian communities: a study protocol to evaluate the effects of a community-inspired awareness-raising and motivational enhancement strategy

INTRODUCTION

Rates of secondhand smoke exposure are currently significantly higher among remote indigenous communities in the top end of Australia. By implementing a 'smoke-free home' rule, secondhand smoke exposure can be reduced. Smoke-free homes encourage quit attempts and improve the health of children. The prevalence of indigenous smoking rates in remote, discrete communities in Australia is elevated compared with their non-indigenous counterparts. The primary aim of this project is to examine the feasibility of conducting a health-driven intervention to encourage community members to make their homes a smoke-free zone.

METHODS AND ANALYSIS

This study uses mixed-methods exploratory evaluation design to obtain data from key informants and community householders to assess their willingness to implement a 'smoke-free' rule in their homes. Initial focus groups will provide guidance on intervention content and deliver evaluation procedures and community requirements. A rapid survey will be conducted to ascertain interest from community members in having the project team visit to discuss study objectives further and to have a particle meter (with consent) placed in the house. Focus groups recordings will be transcribed and analysed thematically. Rapid surveys will be analysed using frequency distributions and tabulations of responses.

ETHICS AND DISSEMINATION

The National Health and Medical Research Council guidelines on ethical research approaches to indigenous studies will be adhered to. The James Cook University Human Research Ethics Committee has provided ethics approval.

Establishing Smoke-Free Homes in the Indigenous Populations of Australia, New Zealand, Canada and the United States: A Systematic Literature Review

A smoke-free home can have multiple benefits by reducing exposure to secondhand smoke (SHS), supporting quit attempts among active smokers, and discouraging adolescents from taking up smoking. The aim of this review was to summarize the literature on the establishment of smoke-free homes in Indigenous populations and identify the supporting influences and barriers, using the Social Cognitive Theory lens. A search of the Medline, CINAHL, Cochrane Collaboration and PyscINFO databases and manual searches of relevant peer-reviewed literature was completed, focusing on Indigenous populations in developed economies of North America and Oceania. Of 2567 articles identified, 15 studies were included. Ten studies included Indigenous participants only, and of these just three focused entirely on SHS in the home. Knowledge of the harms associated with SHS was the most common theme represented in all the studies. This knowledge fueled parents’ motivation to protect their children from SHS by establishing smoke-free homes. Individuals who approached implementation with confidence, coupled with clear communication about smoke-free home rules were more successful. Barriers included challenges for families with multiple smokers living in the same dwelling. There is limited research regarding managing smoking behaviors in the home among Indigenous populations, even though this approach is a successful catalyst for smoking prevention and cessation. Research to understand the influences that support the establishment of smoke-free homes is required for better-informed intervention studies.

Smoking in Pregnancy Among Indigenous Women in High-Income Countries: A Narrative Review

INTRODUCTION

Pregnant women in socioeconomically disadvantaged circumstances, such as Indigenous women, have a high prevalence of smoking. Tobacco smoking is the most significant reversible risk factor for the health of Indigenous pregnant women and their babies.

METHODS

As researchers working in this specialized area, we conducted a narrative review of the literature on smoking among Indigenous pregnant women in the United States, Canada, New Zealand, and Australia. We summarize prevalence and factors influencing tobacco use, interventions, and evidence gaps for tobacco control and smoking cessation. Recommendations are made for future interventions, policy changes, and much-needed research.

RESULTS

Common themes emerging across the four countries reveal opportunities for cross-cultural collaborative studies and trials. These include the social-normative use of tobacco as barriers to quitting in pregnancy and the need for evaluations of interventions at the family and community level. Socioeconomic disparities underscore the importance of enhancing the implementation and reach of strategies to prevent and reduce prenatal tobacco smoking among Indigenous women. Elders and community health care providers as role models for nontobacco use could be explored. Qualitative work is needed to understand the barriers and opportunities, such as cultural strengths supporting quitting tobacco to develop more effective approaches.

CONCLUSIONS

Although a high-priority group, there remains a dearth of research on Indigenous women's smoking in pregnancy. Studies have assessed knowledge and attitudes to smoking in pregnancy, and small feasibility studies and a few empirical trials have been conducted. Recommendations for promising culturally appropriate cessation interventions have been made. Larger trials are warranted.

IMPLICATIONS

Strategies to support quitting among pregnant Indigenous women need to be multifactorial and take account of the social determinants of smoking including historical antecedents, community norms, cultural strengths, and recognition of individual and community needs. Cross-country research collaborations have the potential to leverage funding, share expertise, and strengthen approaches to tackle an important and poorly attended health disparity that has a profound impact on the entire life course for Indigenous peoples.

Effective strategies to reduce commercial tobacco use in Indigenous communities globally: A systematic review

Background

All over the world, Indigenous populations have remarkably high rates of commercial tobacco use compared to non-Indigenous groups. The high rates of commercial tobacco use in Indigenous populations have led to a variety of health issues and lower life expectancy than the general population. The objectives of this systematic review were to investigate changes in the initiation, consumption and quit rates of commercial tobacco use as well as changes in knowledge, prevalence, community interest, and smoke-free environments in Indigenous populations. We also aimed to understand which interventions had broad reach, what the common elements that supported positive change were and how Aboriginal self-determination was reflected in program implementation.

Methods

We undertook a systematic review of peer-reviewed publications and grey literature selected from seven databases and 43 electronic sources. We included studies between 1994 and 2015 if they addressed an intervention (including provision of a health service or program, education or training programs) aimed to reduce the use of commercial tobacco use in Indigenous communities globally. Systematic cross-regional canvassing of informants in Canada and internationally with knowledge of Indigenous health and/or tobacco control provided further leads about commercial tobacco reduction interventions. We extracted data on program characteristics, study design and learnings including successes and challenges.

Results

In the process of this review, we investigated 73 commercial tobacco control interventions in Indigenous communities globally. These interventions incorporated a myriad of activities to reduce, cease or protect Indigenous peoples from the harms of commercial tobacco use. Interventions were successful in producing positive changes in initiation, consumption and quit rates. Interventions also facilitated increases in the number of smoke-free environments, greater understandings of the harms of commercial tobacco use and a growing community interest in addressing the high rates of commercial tobacco use. Interventions were unable to produce any measured change in prevalence rates.

Conclusions

The extent of this research in Indigenous communities globally suggests a growing prioritization and readiness to address the high rates of commercial tobacco use through the use of both comprehensive and tailored interventions. A comprehensive approach that uses multiple activities, the centring of Aboriginal leadership, long term community investments, and the provision of culturally appropriate health materials and activities appear to have an important influence in producing desired change.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2645-x) contains supplementary material, which is available to authorized users.

Smoking-related knowledge and health risk beliefs in a national sample of Aboriginal and Torres Strait Islander people

OBJECTIVES

To describe general knowledge and perceived risk of the health consequences of smoking among Aboriginal and Torres Strait Islander people; and to assess whether knowledge varies among smokers and whether higher knowledge and perceived risk are associated with quitting.

DESIGN, SETTING AND PARTICIPANTS

The Talking About The Smokes project used quota sampling to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. Baseline survey data were collected from 2522 Aboriginal and Torres Strait Islander adults from April 2012 to October 2013.

MAIN OUTCOME MEASURES

Knowledge of direct effects of smoking and harms of second-hand smoke (SHS), risk minimisation, health worry, and wanting and attempting to quit.

RESULTS

Most Aboriginal and Torres Strait Islander participants who were daily smokers demonstrated knowledge that smoking causes lung cancer (94%), heart disease (89%) and low birthweight (82%), but fewer were aware that it makes diabetes worse (68%). Similarly, almost all daily smokers knew of the harms of SHS: that it is dangerous to non-smokers (90%) and children (95%) and that it causes asthma in children (91%). Levels of knowledge among daily smokers were lower than among non-daily smokers, ex-smokers and never-smokers. Among smokers, greater knowledge of SHS harms was associated with health worry, wanting to quit and having attempted to quit in the past year, but knowledge of direct harms of smoking was not.

CONCLUSION

Lack of basic knowledge about the health consequences of smoking is not an important barrier to trying to quit for Aboriginal and Torres Strait Islander smokers. Framing new messages about the negative health effects of smoking in ways that encompass the health of others is likely to contribute to goal setting and prioritising quitting among Aboriginal and Torres Strait Islander people.