Reflecting on practice - the development of a tobacco brief intervention program for Indigenous people in North Queensland

Full text

Reflecting
on
Practice
-fheDevelopmenlo!a
Tobattn
Britf
InIwt.udinn Progmm
for
Indigenous
People in North Queensland
JANYA
MCCALMAN,'
YVONNE
CADET·JAMES,"
DESLEY
HARVEY,"
JACQUI
LLOYD,'
DEANNE
MINNIECON,"
JAN
PARR,'"
KOMLA
TSEY"
AND
DALLAS
YOUNG'
S
ix
months after the end
of
a
complex pilot Indigenous
health promotion interven-
tion, six members
of
the
implementation
and
evaluation team
met to reflect
on
our practice
of
working
on
the program,
The
discus-
sion was structured using the Four
Rs
model' and reflects our learning
from the challenges
of
working as a
team in developing the tobacco brief
intervention program
for
primary
health care workers.
Recall the sequence of events:
what did
you
do?
When? Where?
Why? How? With whom?
Whlle there
is
international
evi-
dence that brief intervention is
an
effective approach in
assisting
clients to quit smoking,'"
it
had
never been formally trialed with
Indigenous people in Australia.
Hence,
in
1999/2000,
a team
of
health promotion officers from the
Tropical Public Health Unit and
staff
from the Alcohol, Tobacco and Other
Drugs Service
(ATODS),
Queensland
Health worked with health workers
in
Indigenous primary health care ser-
vices
in
north Queensland to devel-
op
and pilot a culturally appropriate
tobacco brief intervention program.
The
team
of
health promotion,
ATODs
and evaluation
staff
came
from diverse backgrounds.
We
were
Indigenous and non-Indigenous,
male
and
female, based in Cairns
and Townsville, practitioners and
academ'lcs and worked for different
organisations. Four people delivered
the program - a Torres Strait Islander
Tropical
Public
Health
man,
an
Aboriginal woman and two
non-Indigenous women; and three
people made
up
the evaluation team
-two Aboriginal and
one'
non-
Indigenous woman. Within our ser-
vices,
we
were supported
by
our
managers and a working party which
met bi-monthly.
The
formative program, which com-
prised a one-day workshop for health
staff
and follow-up support for a six
month period, was piloted
in
three
rural and remote Indigenous health
care services over a period oftwelve
months. The program targeted
health
staff
(doctors, nurses, health
workers, administrative
staff
and
some operational staff) with the
intention
that
brief intervention
would
be
used opportunistically with
clients.
The
program was evaluated
by
staff
from the North Queensland
Health Equalities Promotion Unit at
the School
of
Population Health,
University
of
Queensland. Evaluators
attended each training workshop,
conducted participant observation
and provided feedback to training
facilitators. This was used progres-
sively to adapt and adjust the pro-
gram design
and
delivery.
An
evalua-
tion protocol was developed to
define the roles and responsibilities
of
the intervention and evaluation
teams. It identified the importance
of
building rapport, developing trust
and information sharing in engaging
Indigenous communities, and secur-
ing their participation in program
activities.
As
the evaluation pro-
gressed, working party meetings
pro-
vided a forum for reflecting
on
train-
ing workshops, discussing procedur-
al
and substantive issues, and
pro-
viding feedback.
This article is not about the use-
fulness or effects
of
the program but
rather a reflection of our learning
from the challenges
of
working as a
team in developing a complex
Indigenous health promotion inter-
vention. A detailed description and
evaluation
of
the resultant program
is available elsewhere.'"
Briefly, however, the evaluation
found that more than 90%
of
staff
felt that the training was very good
or all right and the action research
approach was well received.
The
training resulted
in
an
increased
awareness
of
smoking cessation
approaches and some changes in
practice at all three sites. Smoking
by
health workers was considered to
be
a barrier to implementation
of
effective brief tobacco advice, but
the training prompted health workers
to think about their
own
smoking.
While none of
the
staff
or clients
of
the three Primary Health
Care
Services had quit smoking at the
end
of
the six month trial, there had
been a number
of
attempts to quit.
Pregnant women and the health
workers themselves were
most
receptive to advice.
Finally, there were broader struc-
tural and contextual issues,
expressed
by
health workers, which
affected the priority given to tobacco
strategies and the ability
of
health
workers to effect behaviour change
through smoking cessation advice.
J)
North Queensland Health Equalities Promotion Unit, School of Population Health, University of Queensland
III
Queensland
Health.
Alcohol,
Tobacco
and
Other
Drugs
Services
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These included a sense
of
frustra-
tion and fatalism that "smoking
is
a
personal choice". or "nothing
changes". There was also a percep-
tion that giving advice was moral is-
ing.
or "telling people what to do".
The
evaluation concluded
that
while health workers face structural
constraints
in
their attempts to bring
about smoking cessation through
brief intervention. the issue is not
whether they should
be
trained to
deliver best practice smoking cessa-
tion and prevention advice. Rather. it
should be implemented into routine
health service delivery for
Indigenous people and continue to
be refined and supported to take
into account the structural issues
and the broader community context
of
Indigenous health.
Six
months after the end
of
the
pilot program. six members
of
the
implementation and evaluation team
'met to reflect on our practice
of
working
on
the tobacco brief inter-
vention program.
We
did this so that
we
could individually review and
debrief our experiences of working
on
the program and to consider what
lessons or insights might have rele-
vance for the further development
of
this. or other. health promotion pro-
grams. In
effect.
this
reflection
formed part
of
the process evalua-
tion
of
the formative program.'
The
discussion was structured
using the Four
Rs
model.' and sum-
marised to form the first draft
of
this
article.
The
draft was then circulated
to team members and managers.
and
further feedback incorporated.
This reflection is therefore a synthe-
sis
of
our experiences
of
working
on
the pilot program.
Relive
the
experience:
what
was
it
like?
How
did you feel? What were
the highs and lows? How did
it
affect
you?
The
experience
of
piloting the
tobacco brief intervention program
was risky personally and profession-
ally.
It involved working in
new.
chal-
lenging environments and being
pre-
pared to listen. adapt and learn.
Because
it
was formative. being
developed in collaboration with
health workers in Indigenous primary
health care services and also being
evaluated. there were
tensions
inherent in the structure
of
the pro-
gram.
The
health promotion/ATODs
team. local health workers and eval-
uation
staff
each had different roles.
vested interests
and
concerns. None
of
the
staff
knew each other well
prior to the program. and there was
initially a lack
of
clear role definition
and
trust
The
judgement inherent in
evaluation also created
tension
between evaluators and program
staff.
The
environment
in
which
we
were
working -primary health care ser-
vices
in
Indigenous communities -
added to the sensitivity
of
these
working relationships. Some mem-
bers
of
the team had not previously
worked
in
Indigenous communities
or primary health care services and
none
of
the team members had pre-
viously been
to
all
of
the pilot sites.
At
times team members felt uncom-
fortable, confronted
and
insecure.
The
first pilot training program. at
a remote community. was logistically
difficult
Both staff who were desig-
nated to deliver the training became
unavailable due to family commit-
ments and a broken leg. and other
team members had to fill in.
Accommodation
in
the local town
was extremely scarce. resulting
in
our staying
in
a crowded Queensland
Health house. sleeping in swags
on
the floor and sharing beds.
We
had
to share local transport with
staff
involved
in
another health program.
Initially.
we
felt isolated and unsup-
ported.
Although not
an
auspicious start.
the adverse conditions and commu-
nal accommodation
at
remote ser-
vices helped team members to get
to know each other
on
a personal
basis
and
to develop collegiality.
trust
and
mutual respect.
We
had a
commitment to listen. take
on
skills.
accept feedback and progressively
adapt the program. This created a
collaboration and mutual respect
between the team members and
pri-
mary health care service
staff
involved. It worked because
of
flexi-
bility and diversity in our knowledge.
experience and skills underpinned
by
common values.
Each
pilot site presented different
issues
that
affected the way
we
delivered and evaluated the training
program. These included awkward
power dynamics between primary
health care service
staff
members.
misunderstandings about the
pur-
pose of our program (some thought
that it was a quit program for staff).
resistance from smokers and
shy-
ness. Our introduction acknowl-
edged that the program was not a
quit smoking program for
staff
and
that smokers can play a valuable
role
in
tobacco intervention. This
was important
in
redUCing
the initial
suspicion and resistance. particular-
ly from smokers.
Our
audience was very diverse.
Doctors and nurses sought more
complex clinical information. and
administrative
staff
and health work-
ers focused
on
the cultural. practical
or organisational issues related to
implementing the program.
We
had
to keep adapting the information
and style
of
delivery and felt
that
the
program did not always adequately
address concerns.
They
raised complex issues. ques-
tioning
why
tobacco should
be
a
pri-
ority health issue. particularly given
the immediacy
of
health effects
of
alcohol and injury.
They
had varying
opinions about whether health
work-
ers
who
smoke could give advice to
clients about
their
smoking.
Indigenous health workers told us
that it was culturally inappropriate
for them to tell community people
what to do. or particularly to give
advice to elders.
There was also
an
issue about
whether administrative and ancillary
staff
should attend training. or
whether
it
should be directed solely
at health staff.
We
encouraged the
view that all
staff
could
be
involved
in a tobacco brief intervention
pro-
gram.
They
were keen to participate
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in
the evaluation process and both
health
staff
and community mem-
bers were prepared to be very
can-
did and forthcoming about
why
they
smoked,
why
they slipped up and
other personal issues. Some said
that the best thing about the
pro-
gram was that it was being evaluat-
ed
and how it was evaluated,
The
action/research process was
immediate and dynamic. Ongoing
feedback meant that health promo-
tion
staff
were constantly being cri-
tiqued and prompted to change their
preliminary training materials and
approaches, This required
an
open
mind and willingness to forego 'own-
ership'
of
the program.
For
the eval-
uators, experiencing the program
delivery first hand provided back-
ground and context
for
applying
meaning to their evaluation
of
the
program.
Re-interpret
the
experience: what
meaning do you now
attach
to
what happened and how
it
affected
you?
Encouraging a change in the
behaviour
in
health
staff
is challeng-
ing.
We
were very aware from the
outset the limitations
of
behaviour
modification initiatives such as the
tobacco brief intervention. Most
pro-
gram evaluation undertaken
in
Indigenous health settings has con-
sistently found that while the pro-
gram is clearly useful, its ability to
make a difference
is
limited
by
the
broader social, economic and politi-
cal constraints.
The
program was therefore trialed
in
the context
of
an
ethical dilemma
-
we
were providing a program based
on
international best practice,
know-
ing that the broader environmental
constraints constitute barriers to the
effectiveness
of
such interventions
and
that tobacco was not regarded
as a priority health issue in
Indigenous communities, While
we
clearly need to provide best practice
services and information,
it
was also
important
to address tobacco
issues within the context
of
the
broader health context and not to
unnecessarily raise expectations
about likely program outcomes,
These issues need to
be
debated as
part
of
the formative stage
of
pro-
grams such
as
this. Given scarce
resources, money put into one pro-
gram means lost opportunity to do
something else. Cost effectiveness
analysis needs to be incorporated
into program evaluation.
Given differing agendas and priori-
ties
between communities and
health services, issues were also
raised about
how
we
should work
with communities to address tobac-
co (or indeed
any
health priority).
The
extent
of
the lack
of
awareness
about the effects of tobacco was
illustrated in
one
pilot site where
community members were asked if
anybody
in
their community had died
from smoking tobacco. The
response was "yes, one person
killed another
in
a fight over a
bumper (cigarette butt)".
We
found
that community members expected
to be consulted and kept informed
about health initiatives, and that
Indigenous understandings
of
health
and well-being were considered
important
in
the development
of
resources and programs,
In
hindsight, although the diversity
of
our team
was
challenging,
it
was
critical to how
staff
at the pilot sites
received our program, Indigenous
health workers,
in
particular, said
that the Indigenous members
of
our
team helped them to feel comfort-
able, understand language and con-
cepts, address cultural issues and
take part in discussions,
Staff
at
one site also mentioned their appre-
ciation
that
our team included a
male. It is not possible to be all
things to all people. Having a variety
of
perspectives assisted
in
the deliv-
ery
of
tobacco intervention for
staff
and through them, to clients,
To
overcome initial difficulties,
it
would
have been beneficial to have organ-
ised some team building processes
at the
start
of
the program and to
have defined roles more clearly.
Team
members who undertook cul-
tural awareness training prior to the
pilot program found that to be bene-
ficial.
There is still room for improvement
in
both our implementation
'and
eval-
uation process. Although
we
deliber-
ately adopted
an
'insider'-'outsider'
collaborative evaluation process to
overcome the traditional
'us'
and
'them' approach
to
evaluation, some
program
staff
clearly found the draft
report (which was intended to stimu-
late and solicit
data
for the final
report) confronting and some evalu-
ation
staff
also found comments
from program
staff
difficult.
As
eval-
uators,
we
often fail to adequately
explain the processes and principles
involved to
key
stakeholders, includ-
ing program staff.
Finally,
we
carefully explored
options for both quantitative and
qualitative approaches to evaluating
this program. However, the costs
of
doing a quantitative evaluation in a
meaningful
way
were exorbitant.
We
felt that to undertake outcome eval-
uation in the area
of
tobacco brief
intervention,
we
either needed to
find the resources and
do
it properly
or not do it at all!
We
opted for the
latter.
Respond: is there anything you
should do in response
to
what
you
have learned? What is
it?
Why is
this
appropriate?
Tobacco is the largest preventable
cause
of
death and disability
in
Indigenous communities, yet lacks
priority as a health issue. Health
staff
have
not
been trained or
expected to consistently address the
smoking behaviour
of
their clients.
There is a sense
of
fatalism among
staff
about tobacco smoking in
Indigenous communities, This is
understandable given the high rate
of
smoking, prevalence
of
other
pressing health problems, and lack
of
social pressure to quit. A health
service-based brief intervention
approach is unlikely to
be
effective
unless it
is
linked with broader com-
munity awareness and harm minimi-
sation strategies.
We
need to develop further strate-
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gies for engaging Indigenous
com-
munities around tobacco issues. A
whole
of
community response needs
to involve the community from the
start and include multiple strategies
that address both the immediate
and
long-term effects
of
smoking
and incorporate
an
Indigenous
understanding
of
health.
The
evalua-
tion team found that community
peo-
ple had ideas
on
what tobacco
strategies would work
in
their
com-
munity across sectors.
When
developing health programs,
we
need to re-examine our
own
assumptions about program aims
and
expectations. These need to
take the community context and
con-
cerns into account,
and
be realistic.
For
example, it is probably not real-
istic
to
expect that brief intervention
as
a Single strategy within
Indigenous setting will reduce smok-
ing
rates. However, it should assist
in
creating a trained workforce which
can
make a difference
in
assisting
people to address their
own
smoking
issues.
We
also need to recognise
and
acknowledge the need for organ-
isational systems within health ser-
vices to integrate and adopt the
pro-
gram
on
a
day
to
day
basis.
Follow-
up
systems
are
needed to support
such programs.
We
need to focus
on
the develop-
ment
of
multiple community based
strategies within a harm minimisa-
tion framework. Brief intervention
should be supported
by
community
awareness strategies, prevention
of
uptake strategies and more support-
ive
cessation strategies.
hc«
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CARE
COMPLAINTS
COMMISSION
Traditionally, tobacco strategies
have focused
on
prevention or ces-
sation strategies, and been suspi-
cious
of
harm minimisation frame-
works. However, within Indigenous
communities, where
most
adults
smoke and are not well-informed,
motivated or supported to quit, a
harm minimisation approach gives
more opportunities
for
success.
Under a cessation framework,
suc-
cess is defined only as quitting.
Under a harm minimisation frame-
work
it
may
be defined
by
quitting,
cutting back or limiting the times or
areas where a person smokes. This
approach could also reduce the
sense
of
fatalism felt
by
health work-
ers in their attempts to address
tobacco issues with clients.
Finally,
we
support the process
by
which this tobacco brief intervention
program has been developed.
The
process
of
developing tobacco
strategies for Indigenous settings is
risky. It must be done through a col-
laborative process, and evaluation
needs to
be
an
integral component
of
the process.
We
suggest that this
process could
be
used to develop
other health interventions such
as
alcohol, cannabis, nutrition, and
phySical activity within Indigenous
communities.
Key
words
Indigenous, tobacco, brief inter-
vention, reflection
Acknowledgment
All
health staff, managers and
community members who participat-
ed
in
the pilot program.
References.
1.
Kottke
TE,
Battista
RN,
DeFriese
GH,
Brekke
ML.
(1988). Attributes
of
successful smoking cessation inter-
ventions
in
medical practice. Journal
of
the American Medical
Association,
Vol
259,
No
19, 2883-
2889.
2.
Raw
M, McNeill
A,
West
R.
(1999). Smoking cessation: evi-
dence based recommendations for
the health care system. British
Medical Journal,
318,
182-185.
3. Harvey
D,
Tsey
K,
Cadet James
Y,
Minniecon
D,
Ivers R
and
Hunter
E.
(August 2001). 'Evaluation
of
the
pilot phase
of
Queensland Health
brief intervention training in
Indigenous health settings'.
Final
Report. North Queensland Health
Equalities Promotion Unit, School
of
Population Health, University
of
Queensland, Cairns.
4.
Harvey
D,
Tsey
K,
Cadet-James
Y,
Minniecon
D,
Ivers
R,
McCalman
J,
Lloyd
J,
Young
D.
An
evaluation
of
tobacco brief intervention training
in
three Indigenous health care set-
tings in north Queensland,
Australian and
New
Zealand Journal
of
Public Health (submitted).
5.
Hawe
P,
Degeling
D,
Hall
J.
Evaluating Health Promotion: A
Health Workers'
Guide.
McLennan
and
Petty,
1995.
6.
McKenzie B and MacAdam
R.
Systemic Development Institute,
University
of
New
South Wales.
Monograph
1996
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