Anette Kira

A systematic review of barriers and facilitators to participation in randomized controlled trials by Indigenous people from New Zealand, Australia, Canada and the United States

Issue: Many randomized controlled trials (RCTs) are conducted each year but only a small proportion is specifically designed for Indigenous people. In this review we consider the challenges of participation in RCTs for Indigenous peoples from New Zealand, Australia, Canada and the United States and the opportunities for increasing participation. Approach: The literature was systematically searched for published articles including information on the barriers and facilitators for Indigenous people’s participation in health-related RCTs. Articles were identified using a key word search of electronic databases (Scopus, Medline and EMBASE). To be included, papers had to include in their published work at least one aspect of their RCT that was either a barrier and/or facilitator for participation identified from, for example, design of intervention, or discussion sections of articles. Articles that were reviews, discussions, opinion pieces or rationale/methodology were excluded. Results were analysed inductively, allowing themes to emerge from the data. Key findings: Facilitators enabling Indigenous people’s participation in RCTs included relationship and partnership building, employing Indigenous staff, drawing on Indigenous knowledge models, targeted recruitment techniques and adapting study material. Challenges for participation included both participant-level factors (such as a distrust of research) and RCT-level factors (including inadequately addressing likely participant barriers (phone availability, travel costs), and a lack of recognition or incorporation of Indigenous knowledge systems. Implication: The findings from our review add to the body of knowledge on elimination of health disparities, by identifying effective and practical strategies for conducting and engaging Indigenous peoples with RCTs. Future trials that seek to benefit Indigenous peoples should actively involve Indigenous research partners, and respect and draw on pertinent Indigenous knowledge and values. This review has the potential to assist in the design of such studies.

Keeping Kids Smokefree: rationale, design, and implementation of a community, school, and family-based intervention to modify behaviors related to smoking among Māori and Pacific Island children in New Zealand.

Despite a concerted, sustained and comprehensive tobacco control effort, smoking is prevalent among young people in New Zealand, particularly for Māori and Pacific Island teenagers. Many took up smoking in their pre-teen years. New Zealand research has shown that daily smoking by children aged 14–15 years is strongly influenced by parental smoking. The Keeping Kids Smokefree study is investigating whether changing parental smoking behavior and attitudes via a community-partnership approach with parents, schools, and local health providers can reduce smoking initiation by 11–12 year olds. It is a quasi-experimental trial involving four schools in an urban area of high social deprivation with large numbers of Māori and Pacific Islands families. Schools were allocated to intervention or control and the intervention was developed through a process of engagement with the schools, parents of children and local healthcare organizations. This article describes the rationale, context, methodology and methods involved in establishing the study. Building Māori and Pacific Islander research capacity was a secondary objective of the study.

Publications as an Indicator of Increased Tobacco Control Research Productivity (Quantity and Quality) in New Zealand

INTRODUCTION Tobacco control (TC) research capacity and productivity are critical for developing evidence-informed interventions that will reduce the harmful effects of smoking. The aim of this paper was to investigate New Zealands (NZ) TC research capacity along with the quantity and quality of publications, following two government initiatives aimed, in part, at improving the quantity and quality of NZ TC research. METHOD Scopus was searched for articles with at least one NZ author and where the topic was of primary relevance to TC. Publications were organized into two time periods, following the government initiatives, 1993-2003 and 2004-2009. We analyzed the number of publications, publication journals, type of publications, impact (using the impact factor), and authorship. RESULTS There has been an increase in number and impact of publications and number of authors. The number of publications has increased from an average of 14 (1994-2003) to 38 per year (2004-2009). The number of journals published increased from 64 to 86. The impact during 2004-2009 was almost threefold than in 1993-2003. The number of authors increased from 212 to 345, and the number of authors who had at least one first-authored publication increased from 80 to 124. CONCLUSIONS These results show an encouraging trend in NZ TC research, with an increase in research productivity, quality, and in research capacity. It is possible that government-initiated and -funded infrastructural support contributed to increasing needed TC research, which supports the worth of such initiatives.

Smoking in Pregnancy Among Indigenous Women in High-Income Countries: A Narrative Review

Introduction Pregnant women in socioeconomically disadvantaged circumstances, such as Indigenous women, have a high prevalence of smoking. Tobacco smoking is the most significant reversible risk factor for the health of Indigenous pregnant women and their babies. Methods As researchers working in this specialized area, we conducted a narrative review of the literature on smoking among Indigenous pregnant women in the United States, Canada, New Zealand, and Australia. We summarize prevalence and factors influencing tobacco use, interventions, and evidence gaps for tobacco control and smoking cessation. Recommendations are made for future interventions, policy changes, and much-needed research. Results Common themes emerging across the four countries reveal opportunities for cross-cultural collaborative studies and trials. These include the social-normative use of tobacco as barriers to quitting in pregnancy and the need for evaluations of interventions at the family and community level. Socioeconomic disparities underscore the importance of enhancing the implementation and reach of strategies to prevent and reduce prenatal tobacco smoking among Indigenous women. Elders and community health care providers as role models for nontobacco use could be explored. Qualitative work is needed to understand the barriers and opportunities, such as cultural strengths supporting quitting tobacco to develop more effective approaches. Conclusions Although a high-priority group, there remains a dearth of research on Indigenous womens smoking in pregnancy. Studies have assessed knowledge and attitudes to smoking in pregnancy, and small feasibility studies and a few empirical trials have been conducted. Recommendations for promising culturally appropriate cessation interventions have been made. Larger trials are warranted. Implications Strategies to support quitting among pregnant Indigenous women need to be multifactorial and take account of the social determinants of smoking including historical antecedents, community norms, cultural strengths, and recognition of individual and community needs. Cross-country research collaborations have the potential to leverage funding, share expertise, and strengthen approaches to tackle an important and poorly attended health disparity that has a profound impact on the entire life course for Indigenous peoples.

An innovative team-based stop smoking competition among Māori and Pacific Island smokers: rationale and method for the study and its evaluation

BackgroundMāori and Pacific Island people have significantly higher smoking rates compared to the rest of the New Zealand population. The main aim of this paper is to describe how knowledge of Indigenous people’s practices and principles can be combined with proven effective smoking cessation support into a cessation intervention appropriate for Indigenous people.Methods/DesignA literature review was conducted to identify what cultural principles and practices could be used to increase salience, and what competition elements could have an impact on efficacy of smoking cessation. The identified elements were incorporated into the design of a cessation intervention.DiscussionCultural practices incorporated into the intervention include having a holistic family or group-centred focus, inter-group competitiveness, fundraising and ritual pledging. Competition elements included are social support, pharmacotherapy use, cash prize incentives and the use of a dedicated website and iPad application. A pre-test post-test will be combined with process evaluation to evaluate if the competition results in triggering mass-quitting, utilisation of pharmacotherapy and in increasing sustained smoking cessation and to get a comprehensive understanding of the way in which they contribute to the effect. The present study is the first to describe how knowledge about cultural practices and principles can be combined with proven cessation support into a smoking cessation contest. The findings from this study are promising and further more rigorous testing is warranted.

Recruiting Pregnant Indigenous Women Who Smoke into a High Contact Incentivized Cessation Trial: A Feasibility Study

INTRODUCTION Smoking prevalence among pregnant indigenous women is disproportionately higher than for nonindigenous pregnant women. Incentives have been shown to increase retention in and the effectiveness of smoking cessation programs. To trial if this could work for indigenous women, we aimed to recruit and observe retention of Māori (New Zealand indigenous people) pregnant women that smoke into a cessation program using incentives. METHODS A parallel group, randomized controlled feasibility trial was undertaken in New Zealand. Pregnant Māori women who smoked were recruited through health practitioners, social media, and general media advertising. Outcomes included ease of recruitment, enrollment rate, retention, cost, and time and distance traveled to visit participants. RESULTS Seventy-four women were referred for the trial over 7 months. The highest enrollment rate was among self-referrals from media (6 of 10), then women referred from cessation providers (47%, 8 of 17). About three-quarters of women referred from health professionals did not enroll. Only 32% (24) were randomized. Nine women completed the intervention, three withdrew, and 12 were lost to follow-up. On average, it took less time to contact abstinent participants (29 vs. 43 minutes for nonabstinent women). No deception was noted. CONCLUSIONS Recruitment was difficult and varied by source of first contact. Once enrolled, it was feasible to maintain intensive contact with participants who stayed engaged. The number lost to follow-up was high. We concluded that the tenor of trial promotion could have influenced recruitment and retention rates. Further research with indigenous women is needed to identify better recruitment and retention methods. IMPLICATION With the rising cost of research and the increased competition for funds, it is important to have evidence that intervention studies with minority group pregnant women who smoke are feasible. Maintaining contact with participants seemed feasible, but the tenor of trial promotion and type of recruitment strategy could influence enrollment and retention of sufficient numbers of participants. Nonjudgmental supportive advertising and invitations direct to women may work better than relying on health professionals as recruiters.

Smoke, smoking and cessation: the views of children with respiratory illness

Abstract Objective: To explore the attitudes of Māori (indigenous New Zealanders) and Pacific children with respiratory illness towards smoking, secondhand smoke (SHS) and smoking cessation. Methods: Forty-one Māori and Pacific children (aged 6–11 years) in New Zealand (NZ) were interviewed about their attitudes towards smoking, how SHS affects them and their respiratory disease, ideas they have about how to reduce SHS exposure, their fears and concerns about smoking, and experience asking parents to quit smoking. The interviews were transcribed and deductively analysed. Results: The children said that SHS made them feel “bad,” “angry,” “uncomfortable” and “really sick,” making them want to get away from the smoke. They were aware that smoking “is dangerous” and that “you could die from it.” Many children had fears for smokers around them. The children reported on rules restricting smoking around children: “You’re not allowed smoke in the car where babies are.” A number of children reported that adults complied with those rules, but some reported that people still smoked around them. The children had experienced people around them quitting and had an awareness of how difficult it is to quit smoking. The most common reason perceived for quitting was concern for children. A lot of the children thought they could ask parents to quit and other suggestions included hiding people’s tobacco, and use of smoke-free pamphlets, or signs. Conclusions: Even young children from low socioeconomic minority groups are aware of the dangers of smoking and SHS, and hold negative views about smoking. Health promotion messages for parents could have more weight if they convey the concerns voiced by children.