Role of organisational factors on uptake and implementation of the B.strong brief intervention training program in Queensland Indigenous primary health care services.

ISSUE ADDRESSED: The B.strong Program was an Indigenous health worker brief intervention (BI) training program delivered in Queensland from 2017-2020. This study examines the organisational factors of participating Indigenous primary health care (PHC) services that impacted on B.strong's uptake and implementation in those services. METHODS: Semi-structured interviews were conducted from 2019-2020 with 20 B.strong Program trainees and four health service managers from eight purposively sampled Queensland PHC services, and one Queensland Department of Health manager, to examine their perceptions of uptake and implementation of the B.strong Program. The Consolidated Framework for Implementation Research was used as a framework for the evaluation. Data analysis was conducted using NVivo 11. RESULTS: Although strong PHC service support was evident for the uptake of face-to-face workshop training, it was not available to support trainees to complete online modules or for ongoing BI delivery to clients. Key organisational factors associated with both program uptake and implementation of BIs in PHC services were leadership engagement and implementation climate. Within these themes, embedding B.strong into operational practices of health services, having policies, processes and consistent administrative support to facilitate implementation, and addressing gaps in knowledge and skills of health workers were identified as needing to be improved. The study identified the lack of application of continuous quality improvement (CQI) processes to BIs at these health services as a barrier to effective implementation. CONCLUSIONS: The study supports the establishment of BI specific CQI initiatives in health services and supports better engagement with organisational leadership in BI training to ensure their ongoing support of both the training and implementation of BI.

Perceived impact of the characteristics of the Indigenous Queensland B.strong brief intervention training program on uptake and implementation.

ISSUE ADDRESSED: Brief interventions (BIs) in primary health care (PHC) settings can be effective in addressing behavioural risk factors of chronic conditions. However, the impact of the characteristics of BI training programs on the uptake of the program and implementation of BIs in Indigenous PHC settings is not fully understood. The B.strong Program was an Indigenous health worker BI training program delivered in Queensland from 2017 to 2020. This study examines the impact of the characteristics of the B.strong Program on its uptake and implementation in PHC settings. METHODS: Semi-structured interviews were conducted in 2019 and 2020 with 20 B.strong Program trainees and four health service managers from eight purposively sampled Queensland PHC services, and one Queensland Department of Health manager, to collect their perceptions of the implementation of the B.strong Program. The Consolidated Framework for Implementation Research guided data collection. RESULTS: Key program characteristics that facilitated both the program uptake and the implementation of BIs were: ensuring the cultural appropriateness of the program from development, to engagement with health services and through to delivery, the applicability of the program to trainees' daily clinical work, program credibility, and its ease of access and availability. Participants preferred face-to-face workshop training for online module training. CONCLUSIONS: Relevance to practice, easy access, program credibility and measures taken to ensure cultural appropriateness of the B.strong Program in development, in engagement stages with health services, and in program delivery facilitated program uptake and implementation of BIs. Online BI training may be of limited value compared to face-to-face training in this setting. SO WHAT?: To enhance participation by Indigenous PHC services in health worker BI training programs and implementation of BIs posttraining by health staff, it is important to ensure the cultural appropriateness of the program's characteristics, and its development, engagement and delivery processes.

Notes From the Field: Applying the Consolidated Framework for Implementation Research in a Qualitative Evaluation of Implementation of the Queensland Aboriginal and Torres Strait Islander Brief Intervention Training Program.

This paper describes the applicability of the Consolidated Framework for Implementation Research (CFIR) to the qualitative evaluation of the implementation of the Queensland Aboriginal and Torres Strait Islander Brief Intervention Training Program, the B.strong Program. Interviews were conducted with 20 B.strong Program trainees and four health service managers from eight purposively sampled Indigenous primary health care services in Queensland to collect their perceptions of the B.strong Program implementation. The 26 constructs of the CFIR were used to guide data collection and analysis. Additional constructs were developed for two program implementation aspects, "quality improvement" and "cultural suitability." Findings are presented from the application of the CFIR to the evaluation of the implementation of a brief intervention training program in the Australian Indigenous context. While demonstrating the applicability of the CFIR in this evaluation, this study also highlights that it may require modification, to ensure identification of the different contextual factors that influence program implementation.

Using Pharmaceutical Benefit Scheme data to understand the use of smoking cessation medicines by Aboriginal and Torres Strait Islander smokers.

OBJECTIVE: To examine the supply of smoking cessation medicines to Aboriginal and Torres Strait Islander smokers compared to non-Indigenous smokers across Australia. METHODS: We analysed the total number of smoking cessation prescriptions dispensed over three years through the Pharmaceutical Benefits Scheme (PBS) compared to those supplied nationally through the Closing the Gap (CTG) measure and also in the Northern Territory through the Remote Area Aboriginal Health Service (RAAHS) program. RESULTS: Aboriginal and Torres Strait Islander smokers were supplied with fewer smoking cessation medicines per smoker under the CTG measure compared to non-Indigenous smokers under general PBS benefits. Supply of medicines though the RAAHS program complicated the use of CTG data where higher proportions of Aboriginal and Torres Strait Islander people live in remote areas and use of the CTG measure is lower. CONCLUSIONS: Fewer smoking cessation medicines are being prescribed and then dispensed to Aboriginal and Torres Strait Islander smokers than to non-Indigenous smokers. Implications for public health: CTG and RAAHS data may be useful to monitor and evaluate the effectiveness of interventions to improve the use of smoking cessation medicines by Aboriginal and Torres Strait Islander smokers. However, there are limitations and current obstacles to accessing RAAHS data would need to be removed.

Impact of three annual tobacco tax rises on tobacco sales in remote Australian Aboriginal community stores.

BACKGROUND: There is strong evidence from many settings that tobacco tax rises which increase prices reduce tobacco consumption, but only limited evidence from Indigenous settings. METHODS: We analysed 3 years (2016-2018) of weekly sales data from 32 stores in remote Aboriginal communities. We used interrupted time series analysis to estimate the immediate impact of the price rice following annual 12.5% tobacco tax rises on sales on (A) stick equivalents of tobacco and (B) fruit and vegetables (kg) per $A1000 of grocery sales, and on the trend in sales between price rises. RESULTS: We detected 5.8% and 8.2% immediate declines in tobacco sales following the price rises associated with annual 12.5% tax rises in 2016 and 2018, and a non-significant decline (1.6%) following the 2017 tax rise. Decreased sales were mainly driven by declines in mainstream and premium factory-made cigarettes. Fruit and vegetable sales did not change at the time of tobacco price rises. CONCLUSION: For the first time, we demonstrated evidence of price-sensitivity and the immediate impact of price rises from tobacco tax rises on tobacco sales in remote Aboriginal communities. We acknowledge that Australia already has very high tobacco taxation and prices, but recommend further increases to the taxation of roll-your-own (RYO) tobacco to prevent smokers and industry using cheaper RYO cigarettes to undermine this impact of high tobacco taxes and prices.

The decline of smoking initiation among Aboriginal and Torres Strait Islander secondary students: implications for future policy.

OBJECTIVE: Smoking is a major cause of preventable illness for Aboriginal and Torres Strait Islander people, with most commencing in adolescence. Understanding trends in youth tobacco use can inform prevention policies and programs. METHODS: Logistic regression models examined smoking trends among Aboriginal and Torres Strait Islander and all students aged 12-17 years, in five nationally representative triennial surveys, 2005-2017. Outcomes measured lifetime, past month, past week tobacco use and number of cigarettes smoked daily (smoking intensity). RESULTS: Aboriginal and Torres Strait Islander students' never smoking increased (2005: 49%, 2017: 70%) with corresponding declines in past month and week smoking. Smoking intensity reduced among current smokers (low intensity increased 2005: 67%, 2017: 77%). Trends over time were similar for Aboriginal and Torres Strait Islander students as for all students (8-10% annual increase in never smoking). CONCLUSIONS: Most Aboriginal and Torres Strait Islander students are now never smokers. Comparable declines indicate similar policy impact for Aboriginal and Torres Strait Islander and all students. Implications for Public Health: Comprehensive population-based tobacco control policies can impact all students. Continued investment, including in communities, is needed to maintain and accelerate reductions among Aboriginal and Torres Strait Islander students to achieve equivalent prevalence rates and reduce health inequities.

Factors Impacting on Development and Implementation of Training Programs for Health Professionals to Deliver Brief Interventions, with a Focus on Programs Developed for Indigenous Clients: A Literature Review.

This paper reviews the literature on evaluations of brief intervention training programs for health professionals which address one or more lifestyle factors of chronic disease to identify factors impacting on development and implementation of programs. A search was conducted of the literature evaluating brief intervention training programs from 2000-2019 in the databases: Medline, CINAHL, Psychinfo, Academic Premier, Science Direct, Ovid (Including EMBASE and Healthstar), Web of Science and Informit. The content analysis and data extraction were aligned to the domains in the Consolidated Framework for Implementation Research (CFIR) to assist in the narrative synthesis. The search identified eight evaluations of programs targeting multiple risk factors, and 17 targeting single risk factors. The behavioural risk factor most commonly addressed was smoking, followed by alcohol and drug use. Programs consisted of face-to-face workshops and/or online or distance learning methods. Facilitators included availability of sustainable funding, adapting the program to suit the organisation's structural characteristics and adoption of the intervention into routine client care. For Indigenous programs, the use of culturally appropriate images and language, consultation with Indigenous communities, and development of resources specific to the communities targeted were important considerations.

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.

Electronic Cigarette Use and Understanding Among a National Sample of Australian Aboriginal and Torres Strait Islander Smokers.

INTRODUCTION: Adult daily smoking prevalence in the Aboriginal and Torres Strait Islander population is 2.8 times that of other Australians. There is little data on prevalence of electronic cigarette (e-cigarette) use among Aboriginal and Torres Strait Islander peoples. We measured e-cigarette use and beliefs about their harmfulness in national samples of Aboriginal and Torres Strait Islander smokers and of all Australian smokers. METHODS: The Talking About the Smokes project interviewed a nationally representative quota sample of 1301 Aboriginal and Torres Strait Islander smokers between August 2013 and August 2014. The Australian Wave 9 survey of the long-running International Tobacco Control Project interviewed 1093 smokers between February and May 2013. Estimates for all Australian smokers were standardized to the age and sex distribution of Aboriginal and Torres Strait Islander smokers. RESULTS: Fewer Aboriginal and Torres Strait Islander than all Australian smokers had tried an e-cigarette (21% vs. 30%). This was in part because of more Aboriginal and Torres Strait Islander smokers having not heard of e-cigarettes. Fewer Aboriginal and Torres Strait Islander smokers than all Australian smokers agreed that e-cigarettes are less harmful than conventional cigarettes (22% vs. 50%). CONCLUSIONS: Many Aboriginal and Torres Strait Islander smokers have used e-cigarettes. However, there is considerable misunderstanding about the relative harm of e-cigarettes compared with conventional cigarettes, in part because of the tight regulatory environment in Australia. IMPLICATIONS: The study describes e-cigarette use and understanding in national samples of Aboriginal and Torres Strait Islander smokers and of all Australian smokers. Only small studies have reported on e-cigarette use in this high smoking prevalence population. Fewer Aboriginal and Torres Strait Islander smokers than all Australian smokers had tried an e-cigarette and fewer agreed that e-cigarettes are less harmful than conventional cigarettes. Australian governments, health authorities, health professionals, and e-cigarette regulations should provide clearer messages that e-cigarettes are less harmful.

Social media and health information sharing among Australian Indigenous people.

Despite the enormous potential of social media for health promotion, there is an inadequate evidence base for how they can be used effectively to influence behaviour. In Australia, research suggests social media use is higher among Aboriginal and Torres Strait Islander people than the general Australian population; however, health promoters need a better understanding of who uses technologies, how and why. This qualitative study investigates what types of health content are being shared among Aboriginal and Torres Strait people through social media networks, as well as how people engage with, and are influenced by, health-related information in their offline life. We present six social media user typologies together with an overview of health content that generated significant interaction. Content ranged from typical health-related issues such as mental health, diet, alcohol, smoking and exercise, through to a range of broader social determinants of health. Social media-based health promotion approaches that build on the social capital generated by supportive online environments may be more likely to generate greater traction than confronting and emotion-inducing approaches used in mass media campaigns for some health topics.

Talking About The Smokes: a large-scale, community-based participatory research project.

OBJECTIVE: To describe the Talking About The Smokes (TATS) project according to the World Health Organization guiding principles for conducting community-based participatory research (PR) involving indigenous peoples, to assist others planning large-scale PR projects. DESIGN, SETTING AND PARTICIPANTS: The TATS project was initiated in Australia in 2010 as part of the International Tobacco Control Policy Evaluation Project, and surveyed a representative sample of 2522 Aboriginal and Torres Strait Islander adults to assess the impact of tobacco control policies. The PR process of the TATS project, which aimed to build partnerships to create equitable conditions for knowledge production, was mapped and summarised onto a framework adapted from the WHO principles. MAIN OUTCOME MEASURES: Processes describing consultation and approval, partnerships and research agreements, communication, funding, ethics and consent, data and benefits of the research. RESULTS: The TATS project involved baseline and follow-up surveys conducted in 34 Aboriginal community-controlled health services and one Torres Strait community. Consistent with the WHO PR principles, the TATS project built on community priorities and strengths through strategic partnerships from project inception, and demonstrated the value of research agreements and trusting relationships to foster shared decision making, capacity building and a commitment to Indigenous data ownership. CONCLUSIONS: Community-based PR methodology, by definition, needs adaptation to local settings and priorities. The TATS project demonstrates that large-scale research can be participatory, with strong Indigenous community engagement and benefits.

Predictors of wanting to quit in a national sample of Aboriginal and Torres Strait Islander smokers.

OBJECTIVE: To describe factors that predict wanting to quit smoking in a national sample of Aboriginal and Torres Strait Islander people. DESIGN, SETTING AND PARTICIPANTS: The Talking About The Smokes (TATS) project used a quota sampling design 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 1643 current smokers between April 2012 and October 2013. MAIN OUTCOME MEASURE: Wanting to quit smoking. RESULTS: More than two-thirds of smokers (70%) said they want to quit. Many factors were associated with wanting to quit, including past quitting activity. Interest in quitting was lower among men and smokers from economically disadvantaged areas, but there was no difference by age, remoteness or other measures of economic disadvantage. Attitudes and beliefs negatively associated with wanting to quit included enjoying smoking and believing quitting to be very difficult, and those positively associated included regretting ever starting to smoke, perceiving that local Aboriginal and Torres Strait Islander community leaders disapprove of smoking, believing non-smokers set a good example to children, worrying about future smoking-related health effects and believing quitting to be beneficial. Reporting support from family and friends was predictive of wanting to quit, but factors related to smoking in the social network were not. Associations with health and wellbeing were mixed. While most tobacco control policy exposure variables were positively associated with wanting to quit, two - receiving advice to quit from a health professional, and recall of targeted anti-tobacco advertising - appeared to have an effect that extended beyond influencing relevant attitudes and beliefs. CONCLUSION: Interest in quitting among Aboriginal and Torres Strait Islander smokers appears to be influenced by a broad range of factors, highlighting the importance of taking a comprehensive approach to tobacco control. Advice from health professionals and targeted advertising appear to be important intervention strategies.

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.

Research methods of Talking About The Smokes: an International Tobacco Control Policy Evaluation Project study with Aboriginal and Torres Strait Islander Australians.

OBJECTIVE: To describe the research methods and baseline sample of the Talking About The Smokes (TATS) project. DESIGN: The TATS project is a collaboration between research institutions and Aboriginal community-controlled health services (ACCHSs) and their state and national representative bodies. It is one of the studies within the International Tobacco Control Policy Evaluation Project, enabling national and international comparisons. It includes a prospective longitudinal study of Aboriginal and Torres Strait Islander smokers and recent ex-smokers; a survey of non-smokers; repeated cross-sectional surveys of ACCHS staff; and descriptions of the tobacco policies and practices at the ACCHSs. Community members completed face-to-face surveys; staff completed surveys on paper or online. We compared potential biases and the distribution of variables common to the main community baseline sample and unweighted and weighted results of the 2008 National Aboriginal and Torres Strait Islander Social Survey (NATSISS). The baseline survey (Wave 1) was conducted between April 2012 and October 2013. SETTING AND PARTICIPANTS: 2522 Aboriginal and Torres Strait Islander people in 35 locations (the communities served by 34 ACCHSs and one community in the Torres Strait), and 645 staff in the ACCHSs. MAIN OUTCOME MEASURES: Sociodemographic and general health indicators, smoking status, number of cigarettes smoked per day and quit attempts. RESULTS: The main community baseline sample closely matched the distribution of the Aboriginal and Torres Strait Islander population in the weighted NATSISS by age, sex, jurisdiction and remoteness. There were inconsistent differences in some sociodemographic factors between our sample and the NATSISS: our sample had higher proportions of unemployed people, but also higher proportions who had completed Year 12 and who lived in more advantaged areas. In both surveys, similar percentages of smokers reported having attempted to quit in the past year, and daily smokers reported similar numbers of cigarettes smoked per day. CONCLUSION: The TATS project provides a detailed and nationally representative description of Aboriginal and Torres Strait Islander smoking behaviour, attitudes, knowledge and exposure to tobacco control activities and policies, and their association with quitting.

Personal attitudes towards smoking in a national sample of Aboriginal and Torres Strait Islander smokers and recent quitters.

OBJECTIVES: To describe attitudes towards smoking in a national sample of Aboriginal and Torres Strait Islander smokers and recent quitters and assess how they are associated with quitting, and to compare these attitudes with those of smokers in the general Australian population. DESIGN, SETTING AND PARTICIPANTS: The Talking About The Smokes project used a quota sampling design to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. We surveyed 1392 daily smokers, 251 non-daily smokers and 78 recent quitters from April 2012 to October 2013. MAIN OUTCOME MEASURES: Personal attitudes towards smoking and quitting, wanting to quit, and attempting to quit in the past year. RESULTS: Aboriginal and Torres Strait Islander daily smokers were less likely than daily smokers in the general Australian population to report enjoying smoking (65% v 81%) and more likely to disagree that smoking is an important part of their life (49% v 38%); other attitudes were similar between the two groups. In the Aboriginal and Torres Strait Islander sample, non-daily smokers generally held less positive attitudes towards smoking compared with daily smokers, and ex-smokers who had quit within the past year reported positive views about quitting. Among the daily smokers, 78% reported regretting starting to smoke and 81% reported spending too much money on cigarettes, both of which were positively associated with wanting and attempting to quit; 32% perceived smoking to be an important part of their life, which was negatively associated with both quit outcomes; and 83% agreed that smoking calms them down when stressed, which was not associated with the quitting outcomes. CONCLUSIONS: Aboriginal and Torres Strait Islander smokers were less likely than those in the general population to report positive reasons to smoke and held similar views about the negative aspects, suggesting that factors other than personal attitudes may be responsible for the high continuing smoking rate in this population.

Social acceptability and desirability of smoking in a national sample of Aboriginal and Torres Strait Islander people.

OBJECTIVES: To describe social normative beliefs about smoking in a national sample of Aboriginal and Torres Strait Islander people, and to assess the relationship of these beliefs with quitting. DESIGN, SETTING AND PARTICIPANTS: The Talking About The Smokes project used a quota sampling design to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. We surveyed 1392 daily smokers, 251 non-daily smokers, 311 ex-smokers and 568 never-smokers from April 2012 to October 2013. MAIN OUTCOME MEASURES: Eight normative beliefs about smoking; wanting and attempting to quit. RESULTS: Compared with daily smokers in the general Australian population, Aboriginal and Torres Strait Islander daily smokers were less likely to report that mainstream society disapproves of smoking (78.5% v 62%). Among Aboriginal and Torres Strait Islander daily smokers, 40% agreed that Aboriginal and Torres Strait Islander community leaders where they live disapprove of smoking, 70% said there are increasingly fewer places they feel comfortable smoking, and most (90%) believed non-smokers set a good example to children. Support for the government to do more to tackle the harm caused by smoking was much higher than in the general Australian population (80% v 47.2%). These five normative beliefs were all associated with wanting to quit. Non-smokers reported low levels of pressure to take up smoking. CONCLUSION: Tobacco control strategies that involve the leadership and participation of local Aboriginal and Torres Strait Islander community leaders, particularly strategies that emphasise protection of others, may be an important means of reinforcing beliefs that smoking is socially unacceptable, thus boosting motivation to quit.