Making salient messages for Indigenous tobacco control

Objectives:\ud \ud The aim of this thesis is to explore how anti-tobacco messages can be made more salient for Indigenous smokers. The research has a focus on Australian Indigenous smokers, in particular pregnant smokers and those of reproductive age. These specific groups were chosen as a focus due to their continued high levels and slow decline of smoking prevalence. Consequently there is a public health imperative for new knowledge in these areas to inform practice and policy. The overarching research questions are: are anti-tobacco messages having an impact on Indigenous Australians; can we do better; if so how?\ud \ud Methods:\ud \ud The thesis uses multiple methodologies dependent on the specific research questions. Five studies are presented that inform two main streams of inquiry: mass media anti-tobacco message development and maternal smoking, with a multi-phase design coming together in an integrated discussion of findings. The methods range from systematic reviews of the literature, interviews and focus groups, community based participatory research, cross-sectional surveys (regional and national), and the validation of psychometric instruments. The qualitative analysis draws from grounded theory, phenomenology and the constant comparative method. Factor and multivariate analyses are employed for the quantitative studies. The Risk Behaviour Diagnosis (RBD) Scale based on the Extended Parallel Process Model (EPPM) informs this work. The RBD Scale comprises measures of perceived efficacy (response and self-efficacy) and perceived threat (susceptibly and severity of threat). Regional studies were conducted in an Indigenous community in New South Wales (NSW), and organisations in most States and Territories in Australia were interviewed in a national study.\ud \ud Results:\ud \ud Study 1: A systematic review of 21 peer-reviewed publications on mass media interventions for smoking cessation among Indigenous peoples in Australia, Canada, New Zealand and the United States revealed that Indigenous peoples in the included populations preferred culturally targeted messages. Some generic anti-tobacco messages were considered by Maori women to be inappropriate for Indigenous peoples. Collectively, the studies included in the review demonstrated that perceived effectiveness and recall of generic messages among Indigenous populations were high but did not translate into increased cessation in Indigenous Australians, American Indians and Alaska Natives. In contrast, studies conducted in New Zealand showed that culturally targeted messages for Maori were as effective in the short-term as generic messages for the general population. Targeted internet-based messages had a positive impact on American Indian smokers. However, fear-based generic messages provoked more calls to the New Zealand Quitline by Maori smokers, compared with a holistic targeted campaign.\ud Study 2: A systematic review of seven Australian studies on knowledge and views about maternal tobacco smoking and barriers for cessation in Aboriginal and Torres Strait Islanders revealed eleven third-order constructs (themes) about maternal Indigenous smoking and cessation, at individual, family and community levels. The review identified pregnancy as an opportunity to encourage positive change where a strong “protector role” is expressed. However, studies included in the review demonstrate that tobacco use in the Indigenous population may be perpetuated by social norms and stressors within the Aboriginal community, insufficient knowledge of smoking harms, and lack of salience of anti-tobacco messages. Overall, the review indicated a lack of awareness among Indigenous people regarding the use of pharmacotherapy.\ud \ud Study 3: Pregnant women, partners and family members in regional NSW participated in focus groups to investigate social and family influences and responses to health messages. The results of this study showed that families were proactively managing smoke-free homes to reduce harm to babies and children, but there were some misconceptions about the age of vulnerability of children to passive smoking. Nicotine cravings were often interpreted as 'stress'. Focus group participants identified that anti-tobacco messages and cessation advice were more salient when they related to women's experiences. As a result of this study, community recommendations were made to improve approaches to maternal smoking.\ud \ud Study 4: In a national survey that targeted health organisations involved in the development of anti-tobacco messages for Indigenous Australians, a two-dimensional non-linear principal component analysis extracted components interpreted as 'cultural understanding' (bottom-up, community-based approaches, deep structures) and 'rigour' (theoretical frameworks, and planned/completed evaluations). Aboriginal Medical Services demonstrated strength in using processes of 'cultural understanding' in their anti-tobacco messages. Organisations orientated to the general population were more likely to evaluate their programs.\ud \ud Study 5: Through a community-based regional study of Aboriginal smokers of reproductive age, the RBD Scale and associated measures were found to be reliable and valid in this population. The majority of participants had high-perceived threat regarding smoking cessation. Participants with high-perceived threat and high-perceived efficacy demonstrated danger control responses. These participants had a high intention to quit and were more likely to keep smoke-free homes. However, those with low-perceived threat and low-perceived efficacy demonstrated fear control responses about the harms of smoking, which included denial and avoidance. Logistical regression indicated that independent predictors of intention to quit smoking within the next three months were high-perceived efficacy and having consulted a health professional in the past.\ud \ud Discussion:\ud \ud Anti-tobacco messages appear to be making an impact internationally for Indigenous peoples in terms or raising awareness, but there is conflicting evidence about whether they translate into quitting behaviour. Culturally targeted messages were preferred by the Indigenous populations in these studies and showed potential for future interventions. In pregnancy, messages appear to lack salience for Indigenous Australians and do not relate to women's lived experiences. Regional Aboriginal smokers in NSW had high-perceived threat levels regarding smoking, but high-perceived efficacy was an independent predictor of intention to quit smoking. Protective attitudes to children and babies were demonstrated by the reported management of smoke-free homes.\ud \ud Anti-tobacco messages could be made more salient, particularly for pregnant smokers. Attention to the twin aspects of 'cultural understanding' and rigour could have importance for the development of culturally targeted anti-tobacco messages, via health promotion campaigns and in clinical encounters. Increased awareness is required regarding Aboriginal community perceptions about the age of susceptibility of children to environmental tobacco smoke, the health risks after cessation, and the use of pharmacotherapy for quitting. Community perceptions could be addressed through culturally appropriate educational approaches.\ud \ud There has been no published peer-reviewed research directly comparing targeted versus generic messages in Indigenous peoples. More exploratory research is needed into attitudes about pharmacotherapy and to determine how evidence-based therapy can be promoted. Tobacco control and cessation messages could potentially improve the quality of quit attempts. Health professional training is warranted to support these endeavours.\ud \ud Conclusion:\ud \ud Indigenous Australian smokers of reproductive age, and Indigenous Australian pregnant smokers are urgently in need of more consistent approaches to motivating and supporting cessation attempts. The thesis has explored new approaches to developing targeted tobacco control messages with higher salience that have the potential to be translated into practice and policy. Further research is required to confirm the use of the RBD Scale in a larger sample, and its practical use to guide the tailoring and targeting of messages. The research significantly aligns with key policies in Australia for Closing the Gap on Indigenous heath, such as the NHMRC Road Map and the Aboriginal and Torres Strait Islander Health Plan. These policies outline the need to evaluate risk factors implicated in chronic conditions that impact on Indigenous health status, build resilience against tobacco in Indigenous communities, foster wellbeing for pregnant women and children, and investigate optimum means of delivering preventive health messages utilising community-based approaches. \ud \u