Social determinants of health

An Australian doctor reflects on a difficult but satisfying 6-week placement at an Ebola Treatment Centre in Freetown, Sierra Leone

Rosalie Schultz FAFPHM, FRACGP, FARGP

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.

Sophia Couzos FAFPHM, FACRRM, FRACGP · Anna K Nicholson GDipPH, BPhty(Hons) · Jennifer M Hunt MPH, FAFPHM, PhD · Maureen E Davey MB BS, FAFPHM · Josephine K May · Pele T Bennet BHSc · Darren W Westphal MPH · David P Thomas MB BS, PhD, FAFPHM

Objectives: To describe past attempts to quit smoking in a national sample of Aboriginal and Torres Strait Islander people, and to compare their quitting activity with that in the general Australian population. 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. We surveyed 1643 smokers and 78 recent quitters between April 2012 and October 2013. Baseline results for daily smokers (n = 1392) are compared with results for daily smokers (n = 1655) from Waves 5 to 8.5 (2006–2012) of the Australian International Tobacco Control Policy Evaluation Project (ITC Project). Main outcome measures: Ever having tried to quit, tried to quit in the past year, sustained a quit attempt for 1 month or more. Results: Compared with the general population, a smaller proportion of Aboriginal and Torres Strait Islander daily smokers had ever tried to quit (TATS, 69% v ITC, 81.4%), but attempts to quit within the past year were similar (TATS, 48% v ITC, 45.7%). More Aboriginal and Torres Strait Islander daily smokers than those in the general population reported sustaining past quit attempts for short periods only. Aboriginal and Torres Strait Islander smokers whose local health services had tobacco control resources were more likely to have tried to quit, whereas men and people who perceived they had experienced racism in the past year were less likely. Younger smokers, those who had gone without essentials due to money spent on smoking, and those who were often unable to afford cigarettes were more likely to have tried to quit in the past year, but less likely to have ever sustained an attempt for 1 month or more. Smokers who were unemployed, those who had not completed Year 12 and those from remote areas were also less likely to sustain a quit attempt. Conclusions: Existing comprehensive tobacco control programs appear to be motivating Aboriginal and Torres Strait Islander smokers to quit but do not appear to overcome challenges in sustaining quit attempts, especially for more disadvantaged smokers and those from remote areas.

Anna K Nicholson GDipPH, BPhty(Hons) · Ron Borland PhD · Maureen E Davey MB BS, FAFPHM · Matthew Stevens PhD, BSc(Hons) · David P Thomas MB BS, PhD, FAFPHM

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.

Anna K Nicholson GDipPH, BPhty(Hons) · Ron Borland PhD · Anke E van der Sterren MPH, MA, BA · Pele T Bennet BHSc · Matthew Stevens PhD, BSc(Hons) · David P Thomas MB BS, PhD, FAFPHM

Objectives: To describe recall of anti-tobacco advertising (mainstream and targeted), pack warning labels, and news stories among a national sample of Aboriginal and Torres Strait Islander smokers, and to assess the association of these messages with attitudes that support quitting, including wanting to quit. Design, setting and participants: A quota sampling design was used to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. We surveyed 1643 Aboriginal and Torres Strait Islander smokers from April 2012 to October 2013. Main outcome measures: Frequency of recall of advertising and information, warning labels and news stories; recall of targeted and local advertising; attitudes about smoking and wanting to quit. Results: More smokers recalled often noticing warning labels in the past month (65%) than recalled advertising and information (45%) or news stories (24%) in the past 6 months. When prompted, most (82%) recalled seeing a television advertisement. Just under half (48%) recalled advertising that featured an Aboriginal or Torres Strait Islander person or artwork (targeted advertising), and 16% recalled targeted advertising from their community (local advertising). Frequent recall of warning labels, news stories and advertising was associated with worry about health and wanting to quit, but only frequent advertising recall was associated with believing that society disapproves of smoking. The magnitude of association with relevant attitudes and wanting to quit increased for targeted and local advertising. Conclusions: Strategies to tackle Aboriginal and Torres Strait Islander smoking should sustain high levels of exposure to anti-tobacco advertising, news stories and warning labels. More targeted and local information may be particularly effective to influence relevant beliefs and subsequently increase quitting.

Anna K Nicholson GDipPH, BPhty(Hons) · Ron Borland PhD · Jasmine Sarin BHSci(IndigHlth) · Sharon Wallace AdvDipHSci · Anke E van der Sterren MPH, MA, BA · Matthew Stevens PhD, BSc(Hons) · David P Thomas MB BS, PhD, FAFPHM

Jewish medical resistance in the Holocaust

Peter C Arnold BSc, MB BCh, BA

n/a

Graham N Meadows MD, MPhil, FRANZCP · Joanne C Enticott PhD · Brett Inder BEc(Hons) · Grant M Russell PhD, MFM, FRACGP · Roger Gurr DPM, MRCPsych, FRANZCP