Approximately 2.8 % of the population of Australia is made up of the Aboriginal and Torres Strait Islanders. Tobacco use among these indigenous communities has been a problem for a long time. According to a study conducted between 2014 and 2015, the prevalence of tobacco smoking among the indigenous community stood at 39% i.e. 39% of indigenous Australians aged 15 and above reported daily smoking of tobacco (Butler, 2010). By gender, smoking rates among males was 42% while in females, the prevalence was 36%. The prevalence of smoking is higher in remote areas (47%) compared to urban establishments (37%). The nature of the problem of smoking among indigenous people in Australia is a public health concern. The problem is attributable to a history that is closely associated with tobacco smoking even before contact with non-indigenous Australians (Kegler, Rigler & Honeycutt 2011). Tobacco smoking is integrated in a number of ceremonies among the Aboriginal people. During the colonial times, the Aboriginal people used tobacco as a form of currency. Their culture has normalized tobacco smoking allowing it to reach epidemic levels.
Today, tobacco smoking is to blame for the high rates of morbidity and mortality recorded among members of the indigenous community. The prevalence of smoking-related illnesses is higher among the Aboriginals: indigenous Australians are 2 or 3 times more likely to be hospitalized with respiratory infections as compared to non-indigenous Australians (Magnus et al., 2011). The quality of life among indigenous Australians in reduced as is evidenced by the average life span in the community which is averagely 15 years lower than the national average. There is presence of scholarly work aimed at determining the reasons for the high prevalence of tobacco smoking among indigenous people. However, a gap exists in terms of studies aimed at developing intervention plans for the promotion of health with regards to smoking. This study attempts to bridge this gap by developing a proposal for a health promotion intervention for reducing the prevalence of tobacco smoking among the indigenous people of Australia.
Aim and Objectives
The broad aim of the study is to develop a health intervention initiative to reduce the prevalence of tobacco smoking among the Aboriginal and Torres Strait Islanders of Australia.
- To develop a program for cessation of tobacco smoking for the Aboriginal land Torres Strait Islanders.
- To determine a methodology for evaluation the effectiveness of the health promotion plan
- To reduce the prevalence of tobacco smoking among indigenous males in Australia
The study will take a qualitative approach i.e. the research will employ qualitative research methods in data collection, sampling, data interpretation and analysis. According to Marcus & So (2014) a qualitative study as opposed to a quantitative study helps the researcher to gain insights into the underlying aspects of the identified research problem, which is tobacco smoking among indigenous Australians. It will also help the researcher to find out the trends that exist in the current health promotion programs in Australia with regard to tobacco control which will aid in developing a tobacco control initiative.
In the study it will be impossible to involve the whole community of Aboriginal and Torres Strait Islanders. As such, a sample will be chosen for the study in order to minimize the cost of the study as well as the study time while still achieving the targeted objectives. As contained in Lee & Casell (2013), the sampling method chosen will help the researcher to yield a sample that is representative of the entire population and exclude bias. The researcher will employ the probability sampling method and specifically, the sample will be selected using the stratified sampling method. The justification for choosing the stratified sampling method arises from the fact that the smoking problem among indigenous Australian can be distinguished along different strata such as age. The study will include participants of age groups 12-17, 18-44 and 45 and above. Individuals from both genders will be involved in the study.
Sample Size and Power
The term sample size is used to refer to the process of selecting the number of observations that will be part of the sample for the study. In any research where inferences about the general population are sought, the sample size is critical to the success of the study (Firth & Bennett 2012). The cost of collecting data to be used in the study is one major determinant in the selection of the sample. The sample size will be a major influence in the determination of the statistical power of the study. To ensure the sample is representative, the study will involve a total of two thousand participants (2000) drawn from both gender. In the strata 12-17, a total of 500 individuals will be selected; another 1500 will be selected from the strata of 18-44 while the remaining 500 will be drawn from the strata 45 and above. This formula will give the researcher a sample that will be representative of the general population.
Data Collection Methods
Given that the study method chosen for the research is qualitative, the methods of data collection will be qualitative as well. Qualitative methods in research are generally intended to conduct an exploration of the phenomena. The instruments involved in the course of the qualitative data collection are more flexible as compared to quantitative methods. They employ a style of elicitation that is iterative and classifies responses to questions. Qualitative data collection more often involves three major methods; in depth interviews, questionnaires and participant observation (Bansal, 2018). Alongside the above, qualitative methods of study also employ the use of focus groups in data collection. Focus groups are good choices for establishing data on the cultural norms of the group or general population with regards to getting the general overview of the problem as a concern to the cultural group.
The researcher intends to apply both the in depth interviews and focus groups to collect data on the study. In depth interviews are necessary in qualitative research because they help the researcher to collect data regarding the histories of the persons (Dowling, Lloyd &Suchet-Pearson 2018). It will aid the study to uncover the experiences and perspectives of the participants on the research problem. Qualitative data collection takes on different forms. It may involve the use of audio recorders or video recorders to capture the interviews. Alternatively the interviews may be recorded in writing i.e. transcripts. This study will use transcripts to record the in depth interviews with participants.
For any research to meet the test of quality, it must make ethical considerations. Ethics in research is the determinant of what is right from what is wrong in the course of the research. Ethics helps to define what is acceptable in the study. As a major ethical concern in this research, no harm should be caused to the participants. The researcher is under obligation to prioritize the dignity and the respect of the participants of the study. In this regard, the full consent of the participants must be obtained before they are included in the study. Tied to the issue of respect and dignity is the matter of confidentiality (Lee & Cassell 2013). All information surrendered to the study should only be used for the purpose of the research and must not be shared with any other persons. The researcher in this study commits to protect the privacy of those involved in the study. As a matter of ethics, the research has also avoided the exaggeration of the research aims and objectives.
The study has limited the research aims and objectives to what is achievable and actionable within the course of the study. In the course of the study, all communication between the researcher and the participants will be done with transparency and in an honest manner. As submitted by Bansal et al., (2018) the researcher also commits to ensure that all information provided in the study is true and correct; misleading and falsification of information is an ethical matter of serious nature and must be avoided by this research proposal. Affiliations to this study in any form are declared as well as any conflicts of interests.
Data analysis takes different forms depending on whether the study is quantitative or qualitative (Thomas & Borland, 2017). In quantitative research, the expectation is that raw data is converted into meaningful data by way of applying critical and analytical thinking (Brockman et al., 2012). It usually includes calculation to determine the frequency of the variables as well as the variations observed between the variables. This is what informs the final position that either rejects or agrees with the hypotheses made in the study. Quantitative research on the other hand is intended to help the researcher to establish trends and patterns in the phenomenon studied in the research. There are two approaches to qualitative data analysis; deductive and inductive approach (Neale 2016). In the deductive approach, the researcher interprets the data based on assumptions predetermined by himself. He/she develops a set of questions to guide the analysis of data. On the contrary, the inductive approach of qualitative data analysis does not premise on precepts of the researcher.
In interpreting and analysis data in this study, the deductive approach will be applied. The rationale is that the researcher will already have a bearing as to the data trends based on the literature. The researcher will employ 2 types of qualitative data analysis methods; content analysis and narrative analysis. In content analysis, the researcher will begin from hypotheses that might emerge in the study and work towards establishing the said trends in the study (Dowling, Lloyd &Suchet-Pearson 2018). The researcher will the make use of a numbering system or color codes to identify different themes in the data. The content analysis will be carried out using the Computer Assisted Qualitative Data Analysis System (CAQDAS). As posited by Neale (2016) CAQDAS will help the researcher to gain insight into the qualitative data without getting into the interpretation. The researcher can then make conclusions premised on the content analysis. CAQDAS enables sorting of enormous data in the form of texts helping the researcher to structure them and facilitate management of data.
This section of the proposal looks at the intervention itself. It describes the features of the health promotion initiative that will be designed to reduce the prevalence of tobacco smoking among the Aboriginal and Torres Strait Islanders of Australia. An overview of the intervention is given, the objectives of the plan are discussed and how the objectives will be met as well as a mechanism for evaluation of the said plan.
The Intervention Goals
This section of the research proposal will highlight the aims that are sought by the intended initiative. It provides a brief recap of the approaches that the initiative will make use of in reaching the objectives which are classified into 2; short term and long term objectives.
The health promotion initiative targets to develop salient messages addressing various aspects of smoking among the indigenous people as a public health concern. There has been a concern that most of the messages that are put out to address issues of smoking among Aboriginal and Torres Strait islanders have lacked relevance among most of the indigenous people (Schofield, Sebastian, Donelly, & Anderson, 2015). In response to this, the initiative must look into existing messages that are already in use by other tobacco control initiatives with a view to modifying them to suit the target population. Stakeholders in the health sector, government, social welfare and the community in general can be involved in coming up with the relevant messages which will then be disseminated through mainstream and social media outlets.
Cessation and Rehabilitation
After carrying out mass media campaigns as outlined in the objective above, the stage will have been set for the commencement of cessation and rehabilitation. Although it is reported that most of the individuals who quit do so on their own volition, research also indicates that cessation programs at some point in life played a role in their decision to quit (Pircher, 2012). Cessation from tobacco smoking is carried out in a 3 phase process which consists of preparation followed by intervention and finally maintenance. Intervention is a stage that involves building capacity and confidence in the smoker to enable them to make the decision to quit. Intervention is the process of assisting the tobacco addict to stop smoking (abstinence). This is then succeeded by maintenance which is multi-pronged and the most important phase of the process.
Maintenance involves guiding the recovering addict through strategies of coping with the new life of non-smoking, providing support to enable cessation as well as alternative behavior in place of smoking. As much as it is true that most successful quitters of smoking do so out of their volition, a support system to provide the right enabling conditions for cessation to take place is very necessary during the process Gartoulla (2013). Sometimes this support is provided by trained health practitioners who are involved in the initiative. Alternatively, the persons seeking cessation can access cessation kits available from both public and voluntary agencies. Other times people are assisted by sources such as books, over the counter products or even tapes. For the health promotion program to be effective, it will avail a variety of these resources so that individuals can chose from them.
The rehabilitation and cessation program will be offered in the form of counseling alongside designated voluntary clinics which can be accessed by individuals for support at any time. As denoted by Flynn et al., (2012) individuals recovering from a physiological nicotine addiction will need to be taken through treatment where nicotine replacement therapies will be administered. Nicotine replacement will be administered in the form of nicotine nortriptyline, varenicline, nicotine lozenges, nicotine gum and sustained release bupropion.
In order to overcome the barriers to effective tobacco control initiatives, sufficient education must be done i.e. training of the persons involved in the health promotion initiative. As Hall et al., (2018) denote lack of sufficient training and capacity building for staff has occasioned the poor performance of most tobacco control programs. Low turnover of the workforce coupled with the tendency of tobacco control services to incline towards response rather than a proactive and preventive approach has also limited the chances of success for programs like this. These aforementioned concerns emphasize the need for training of the personnel involved in the initiative so as to create sufficient capacity in them to be able to handle the individuals who sign up for the cessation program.
Proposed Action Plan
This section of the proposal gives a summary of the implementation plan for the proposed health promotion initiative for tobacco control among the Aboriginal and Torres Strait Islanders. It provides a recap of the strategies and resources that the proposed project will use to achieve set objectives:
Whole of Community Approach
Strategies to bring down the prevalence of tobacco smoking must involve the entire community in order to better the chances of success. The whole of community approach is consistent with the community controlled programs for primary healthcare provision which are supported by academic literature as necessary for a holistic focus on health promotion (Joseph & Gamble 2013). With this approach, the entire community is brought on board right from the family at home, to colleagues in the workplace and schools, neighbors and the community in general. All these groups of people have to be sensitized in order to help provide the right environment for cessation and other tobacco control activities to take place. The whole of community approach proceeds with the assumption that the problem of smoking is not only an issue of the well-being of the individual in terms of their health, but also touches on the emotional welfare of the community.
Cross Sector Approach
The design and implementation of an initiative to reduce the prevalence of tobacco smoking cannot be a one-sectorial affair; tobacco control programs have to bring on board different people in order to get the variety of skill set required to get the job done (Xu et al., 2018). This health promotion initiative will bring on board membership drawn from a variety of sectors, but the principal players shall be health practitioners. These shall include nurses and clinicians who have the knowledge of treatment of persons who are physiological addicts of tobacco smoking. Working with the health practitioners from the National Health Services will also be community health volunteers who shall work to complement efforts within the community. Alongside the health practitioners personnel, from the social services will also be assisting with the community based efforts. Lastly police and the local government officials will also be involved given the fact that the initiative shall seek funding from the state government.
Several tobacco control programs are being implemented in Australia even today but what draws the line between successful and unsuccessful efforts are the components of the initiative. As already mentioned in the objectives, the establishment of cessation and rehabilitation programs will be prioritized in this project. However, cessation and rehabilitation are only the starting points. A health promotion program that intends to reduce the prevalence of tobacco smoking must have an action plan that addresses the underlying issues that contribute to tobacco smoking (West 2017). Research has proven a strong link between high tobacco smoking rates and poor housing, unemployment, and low income. This means that the success of the proposal in reducing the prevalence of tobacco smoking among the Aboriginal and Torres Islanders will depend on the consistency of the effort towards addressing the social disadvantages that predispose them to tobacco smoking (World Health Organization 2015). To this effect, the proposal intends to seek funding from the state and federal government and work alongside the governments to avail better housing as well as income generating activities for the people in order to correct the socio economic disadvantages.
Anticipated Outcomes and Significance
This section of the proposal tackles the outcomes that are anticipated by the study after the implementation period. It also gives a brief preview into the significance of the anticipated outcomes.
At the end of the implementation of the health promotion program, the initiative hopes that it will have influenced a behavioral change in the community. This is going to be possible through the media campaigns that will involve the generation and dissemination of salient messages with the right information on the use of tobacco and its impacts on the health of the users. As argued by Pender (2015) the significance of attaining behavior change is central to the achievement of the overall objectives of the plan. From the literature, high rates of tobacco intake among Aboriginal and Torres Strait Islanders is attributable to the normalization of tobacco smoking among peers in the community. If this attitude and mindset can be transformed, there is a good chance that the individuals will cease the use of tobacco.
Another anticipated outcome is the change of culture and the traditions of the Aboriginal and Torres Strait Islanders. Evidence from literature indicates that for a long time the indigenous people of Australia have engaged in the use of tobacco. They have particularly been chewing and continue to chew dry leaves of native tobacco (Martin et al., 2017). Tobacco smoking has been practiced in the Aboriginal community since the times of colonization. Tobacco smoking is engrossed deeply in the culture of Aboriginal Australians. Even to date, their traditional festivals are celebrated by smoking tobacco in Macassan pipes. According to Victorian Health Promotion Foundation (2014) tobacco was in fact a form of currency for the Aboriginal people in the colonial time. These statements are testaments to the fact that the culture and tradition of the indigenous people is a major enabling factor to the smoking of tobacco and hence the significance of imparting culture changes in the community. Enabling community members to see the downside of tobacco smoking will greatly reduce the prevalence of tobacco smoking.
This section of the proposal provides a mechanism which will be used to measure the success of the strategies to reduce the prevalence of tobacco smoking among the Aboriginals and the Torres Strait Islanders. To introduce the evaluation strategy, the purposes of the evaluation plan are spelled out as adopted from (Sokol et al., 2017).
- To measure the effects of the activities of the project within the community (Aboriginals and Torres Strait Islanders).
- To measure the scope of implementation of the project activities.
- To assess the level of capacity built in the Torres Strait Islanders and Aboriginal people to take part in anti-tobacco programs.
- To measure the achievement of the project objectives and evidence based practice against the set time for the project (3 years).
Figure 1: Summary of the evaluation questions to be addressed by evaluation plan
Evaluation of the Process
This segment is dedicated to the criteria that will be applied in evaluating the intervention process, the action plan as well as the achievement of the objectives of the plan as supported by Lee and So (2014). This part of the evaluation will rely majorly on the program documents in estimating the achievement of program objectives. As posited by Shepherd & Zubrick (2012) data collected by program persons will also be factored in the evaluation of program reach. Program is hereby used to mean the actual number of persons from the targeted community that will have participated in the project. Attendance of the program will be a major factor in weighing the program reach.
Additional data obtained from the records of the National Health Services (NHS) will also be employed in the estimation of key performance indicators as captured in various health promotion policy papers. As suggested by Thomas and Stevens, (2014) the evaluation plan may also include the use of additional qualitative methods such as interviews to get more information on the performance of the project. Apart from interviews, key stakeholders in the project may be supplied with questionnaires to be filled in order to help the evaluation to gather their assessment regarding the project
Tobacco smoking among the Aboriginal and Torres Islanders of Australia is a matter of public health concern as is evidenced from literature. The prevalence of tobacco smoking among the indigenous community has been higher than the national average for Australia over the decades, with the prevalence of tobacco smoking remaining higher among the men. The incidence of tobacco related illnesses such as respiratory and cardiovascular diseases are also on the rise. The intervention seeks to achieve the cessation and rehabilitation for tobacco users from the indigenous community. Also sought in the project is an awareness campaign that disseminates salient messages about the dangers of tobacco smoking and the potential benefits of cessation. A culture and behavioral change is necessary to cement the gains that will be made in the control of tobacco smoking. Ultimately, finding redress for the underlying factors that are associated with high prevalence of tobacco smoking among indigenous people such as poor housing, low income and unemployment will ensure that the gains made are not reversed.
Bansal, P. (2018). New Ways of Seeing through Qualitative Research. Academy of Management Journal, 61(4), 1189–1195. https://doi.org/10.5465/amj.2018.4004
Brockman, T. A., Patten, C. A., Smith, C. M., Hughes, C. A., Sinicrope, P. S., Bonnema, S. M., & Decker, P. A. (2012). Process of counseling support persons to promote smoker treatment utilization. Addiction Research & Theory, 20(6), 466–479. https://doi.org/10.3109/16066359.2012.665966
Butler, R., P. (2010). Low daily smoking estimates derived from sales monitored tobacco use in six remote predominantly Aboriginal communities. Australian & New Zealand Journal of Public Health, 34, S71–S75. https://doi.org/10.1111/j.1753-6405.2010.00557.x
Dowling, R., Lloyd, K., & Suchet-Pearson, S. (2018). Qualitative methods III: Experimenting, picturing, sensing. Progress in Human Geography, 42(5), 779–788. https://doi.org/10.1177/0309132517730941
Firth, D., & Bennett, K. E. (2012). Robust models in probability sampling. Journal of the Royal Statistical Society: Series B (Statistical Methodology), 60(1), 3. Retrieved from https://search.ebscohost.com/login.aspx?direct=true&db=buh&AN=4519768&site=ehost-live
Flynn, B. S., Worden, J. K., Secker-Walker, R. H., Badger, G. J., Geller, B. M., & Costanza, M. C. (2012). Prevention of Cigarette Smoking Through Mass Media Intervention and School Programs. American Journal of Public Health, 82(6), 827–834. Retrieved from https://search.ebscohost.com/login.aspx?direct=true&db=buh&AN=9207200294&site=ehost-live
Gartoulla, R. P. (2013). Australian Public Health Initiatives to control Tobacco Smoking. Journal of Institute of Medicine, 35(3), 62–66. Retrieved from https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=94992096&site=ehost-live
Hall, S. M., Humfleet, G. L., Gasper, J. J., Delucchi, K. L., Hersh, D. F., Guydish, J. R., … Guydish, J. (2018). Cigarette Smoking Cessation Intervention for Buprenorphine Treatment Patients. Nicotine & Tobacco Research, 20(5), 628–635. https://doi.org/10.1093/ntr/ntx113
Joseph, R., & Gamble, C. (2013). Cigarette smoking cessation using family interventions. Mental Health Practice, 16(6), 22–26. Retrieved from https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=86059528&site=ehost-live
Kegler, M. C., Rigler, J., & Honeycutt, S. (2011). The Role of community context in planning and implementing community-based health promotion projects. Evaluation & Program Planning, 34(3), 246–253. https://doi.org/10.1016/j.evalprogplan.2011.03.004
Lee, B., & Cassell, C. (2013). Research Methods and Research Practice: History, Themes and Topics. International Journal of Management Reviews, 15(2), 123–131. https://doi.org/10.1111/ijmr.12012
Lee, C. M. C., & So, E. C. (2014). Chapter 6: Research Methodology: Predictability in Asset Returns. In Foundations & Trends in Accounting (Vol. 9, pp. 207–231). Retrieved from https://search.ebscohost.com/login.aspx?direct=true&db=buh&AN=116345384&site=ehost-live
Magnus, A., Cadilhac, D., Sheppard, L., Cumming, T., Pearce, D., & Carter, R. (2011). Economic Benefits of Achieving Realistic Smoking Cessation Targets in Australia. American Journal of Public Health, 101(2), 321–327. https://doi.org/10.2105/AJPH.2009.191056
Martin, K., Dono, J., Rigney, N., Rayner, J., Sparrow, A., Miller, C., … Bowden, J. (2017). Barriers and facilitators for health professionals referring Aboriginal and Torres Strait Islander tobacco smokers to the Quitline. Australian & New Zealand Journal of Public Health, 41(6), 631–634. https://doi.org/10.1111/1753-6405.12727
Neale, J. (2016). Iterative categorization (IC): a systematic technique for analysing qualitative data. Addiction, 111(6), 1096–1106. https://doi.org/10.1111/add.13314
Pender, N. (2015). The Health Promotion Model Manual. Available https://hdl.handle.net/2027.42/8535043
Pircher, J. (2012). Trend analysis of hospital admissions attributable to tobacco smoking, Northern Territory Aboriginal and non-Aboriginal populations, 1998 to 2009. BMC Public Health, 12(1), 545–550. https://doi.org/10.1186/1471-2458-12-545
Pruss-Ustun, A., Wolf, J., Corvalan, C., Bos, R. & Neira, M. (2016).Preventing disease through healthy environments: A global assessment of the burden of disease from environmental risks. Geneva, Switzerland: World Health Organisation 37(6), 1072–1081. https://doi.org/10.1111/risa.12544
Schofield, T., Sebastian, T., Donelly, M., & Anderson, C. (2015). Tobacco use among Aboriginal and Torres Strait Islander high school students: understanding “the social” and the effects of indigeneity. Australian Aboriginal Studies, 2015(2), 46–57. Retrieved from https://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=112143351&site=ehost-live
Shepherd, C. C. J., Li, J., & Zubrick, S. R. (2012). Social Gradients in the Health of Indigenous Australians. American Journal of Public Health, 102(1), 107–117. https://doi.org/10.2105/AJPH.2011.300354
Sokol, R., Moracco, B., Nelson, S., Rushing, J., Singletary, T., Stanley, K., & Stein, A. (2017). How local health departments work towards health equity. Evaluation & Program Planning, 65, 117–123. http s://doi.org/10.1016/j.evalprogplan.2017.08.002
Thomas, D. P., & Stevens, M. (2014). Aboriginal and Torres Strait Islander smoke-free homes, 2002 to 2008. Australian & New Zealand Journal of Public Health, 38(2), 147–153. https://doi.org/10.1111/1753-6405.12202
Thomas, D. & Borland, R. (2017). The social determinants and starting and sustaining quit attempts in a national sample of Aboriginal and Torres Strait Islander smokers. Australian & New Zealand Journal of Public Health, 41(3), 230–236. https://doi.org/10.1111/1753-6405.12626
Victorian Health Promotion Foundation ‘A‘ŸVicHealth’. (2014). Physical activity, sport andwalking: VicHealth’s Investment Plan (2014-2018). Available: https://www.vichealth.vic.gov. au/~/media/resourcecentre/publicationsandresources/physical%20activity/physactivity-investmentplan-2014-18.pdf?la=en 45
West, R. (2017). Tobacco smoking: Health impact, prevalence, correlates and interventions. Psychology & Health, 32(8), 1018–1036. https://doi.org/10.1080/08870446.2017.1325890
World Health Organization. (2015). WHO recommendations on health promotion interventions for maternal and newborn health. Geneva, Switzerland, WHO 37(6), 1096–1107. https://doi.org/10.1111/risa.12669
Xu, Z., Qi, F., Wang, Y., Jia, X., Lin, P., Geng, M., … Li, S. (2018). Cancer mortality attributable to cigarette smoking in 2005, 2010 and 2015 in Qingdao, China. PLoS ONE, 13(9), 1–11. https://doi.or/10.1371/journal.pone.020422