Laura Twyman

Reaching the hard-to-reach: a systematic review of strategies for improving health and medical research with socially disadvantaged groups

BackgroundThis study aims to review the literature regarding the barriers to sampling, recruitment, participation, and retention of members of socioeconomically disadvantaged groups in health research and strategies for increasing the amount of health research conducted with socially disadvantaged groups.MethodsA systematic review with narrative synthesis was conducted. Searches of electronic databases Medline, PsychInfo, EMBASE, Social Science Index via Web of Knowledge and CINHAL were conducted for English language articles published up to May 2013. Qualitative and quantitative studies as well as literature reviews were included. Articles were included if they reported attempts to increase disadvantaged group participation in research, or the barriers to research with disadvantaged groups. Groups of interest were those described as socially, culturally or financially disadvantaged compared to the majority of society. Eligible articles were categorised according to five phases of research: 1) sampling, 2) recruitment and gaining consent, 3) data collection and measurement, 4) intervention delivery and uptake, and 5) retention and attrition.ResultsIn total, 116 papers from 115 studies met inclusion criteria and 31 previous literature reviews were included. A comprehensive summation of the major barriers to working with various disadvantaged groups is provided, along with proposed strategies for addressing each of the identified types of barriers. Most studies of strategies to address the barriers were of a descriptive nature and only nine studies reported the results of randomised trials.ConclusionsTo tackle the challenges of research with socially disadvantaged groups, and increase their representation in health and medical research, researchers and research institutions need to acknowledge extended timeframes, plan for higher resourcing costs and operate via community partnerships.

Perceived barriers to smoking cessation in selected vulnerable groups: a systematic review of the qualitative and quantitative literature

Objectives To identify barriers that are common and unique to six selected vulnerable groups: low socioeconomic status; Indigenous; mental illness and substance abuse; homeless; prisoners; and at-risk youth. Design A systematic review was carried out to identify the perceived barriers to smoking cessation within six vulnerable groups. Data sources MEDLINE, EMBASE, CINAHL and PsycInfo were searched using keywords and MeSH terms from each databases inception published prior to March 2014. Study selection Studies that provided either qualitative or quantitative (ie, longitudinal, cross-sectional or cohort surveys) descriptions of self-reported perceived barriers to quitting smoking in one of the six aforementioned vulnerable groups were included. Data extraction Two authors independently assessed studies for inclusion and extracted data. Results 65 eligible papers were identified: 24 with low socioeconomic groups, 16 with Indigenous groups, 18 involving people with a mental illness, 3 with homeless groups, 2 involving prisoners and 1 involving at-risk youth. One study identified was carried out with participants who were homeless and addicted to alcohol and/or other drugs. Barriers common to all vulnerable groups included: smoking for stress management, lack of support from health and other service providers, and the high prevalence and acceptability of smoking in vulnerable communities. Unique barriers were identified for people with a mental illness (eg, maintenance of mental health), Indigenous groups (eg, cultural and historical norms), prisoners (eg, living conditions), people who are homeless (eg, competing priorities) and at-risk youth (eg, high accessibility of tobacco). Conclusions Vulnerable groups experience common barriers to smoking cessation, in addition to barriers that are unique to specific vulnerable groups. Individual-level, community-level and social network-level interventions are priority areas for future smoking cessation interventions within vulnerable groups. Trial registration number: A protocol for this review has been registered with PROSPERO International Prospective Register of Systematic Reviews (Identifier: CRD42013005761).

Electronic Cigarettes: Awareness, Recent Use, and Attitudes Within a Sample of Socioeconomically Disadvantaged Australian Smokers.

INTRODUCTION Electronic cigarette (e-cigarette) awareness, trial of e-cigarettes in the past 12 months, source and perceptions of safety and effectiveness was assessed within a disadvantaged sample of adult Australian smokers receiving welfare aid. METHODS A cross-sectional survey was administered to clients who smoke at two community service organizations in New South Wales, Australia from October 2013 to July 2014. E-cigarette awareness, trial in past 12 months, sources of e-cigarettes and perceptions of the safety and effectiveness of e-cigarettes to help people quit were assessed along with sociodemographic and smoking-related variables. RESULTS In total, 369 participants completed the survey (77% response rate). Awareness and trial of e-cigarettes were reported by 77% (n = 283) and 35% (n = 103) of the sample, respectively. E-cigarettes were most commonly obtained from friends/strangers followed by tobacco shops (tobacconists). Trying e-cigarettes in the past 12 months was significantly associated with positive perceptions of their safety (odds ratio [OR] = 1.8, 95% confidence interval [CI] = 1, 3.1) and effectiveness (OR = 1.9, 95% CI = 1.1, 3.2). Motivation to quit tobacco smoking was also significantly positively associated with positive perceptions of e-cigarette safety (OR = 1.2, 95% CI = 1.1, 1.4) and effectiveness (OR = 1.2, 95% CI = 1.0, 1.3). CONCLUSIONS Rates of awareness and trial of e-cigarettes within a disadvantaged sample of Australian smokers are comparable to rates found within representative samples of the general Australian population. Previously trying e-cigarettes and higher levels of motivation to quit were associated with more positive perceptions of e-cigarette safety and effectiveness. IMPLICATIONS This study demonstrates that socioeconomically disadvantaged smokers are aware of and accessing e-cigarettes in a country with relatively high restrictions covering e-cigarette sale and use.

Factors Associated With Concurrent Tobacco Smoking and Heavy Alcohol Consumption Within a Socioeconomically Disadvantaged Australian Sample

ABSTRACT Background: Tobacco use and heavy alcohol consumption occur more frequently in socioeconomically disadvantaged groups. Little is known about the sociodemographic and psychosocial factors associated with use of alcohol and tobacco in disadvantaged groups in comparison to low-risk users. Objectives: This study aimed to compare the characteristics of low-risk users with: disadvantaged smokers only; disadvantaged heavy drinkers only; and disadvantaged concurrent smokers and heavy drinkers. Methods: A cross-sectional survey of socioeconomically disadvantaged adult clients attending a community welfare agency assessed tobacco use, alcohol use, demographic, and psychosocial variables. Multivariable analysis using multinomial logistic regression was carried out. Results: The sample consisted of 835 participants; 40% (n = 331) were concurrent users, 31% were smokers only (n = 252), 11% were heavy drinkers only (n = 93), and 18% were low-risk users (n = 149). Compared with those who neither smoked nor consumed alcohol heavily, concurrent users were more likely to be younger, have only some contact with family, have more friends and family who were smokers, have no fixed home address, live alone, and have higher levels of financial stress. Most of these factors were shared by individuals who were smokers only. Factors associated with heavy drinkers only were frequent contact with family and having more friends and family who were smokers. Conclusion: Among those Australians who suffer severe economic hardship, being a concurrent smoker and heavy drinker appears to be associated with more isolated living conditions and financial stress but some contact with family.

Financial Stress and Smoking within a Large Sample of Socially Disadvantaged Australians

Financial stress is associated with fewer quit attempts and higher relapse rates. This study aimed to compare financial stress among smokers, ex-smokers and never smokers in a highly socioeconomically disadvantaged sample. The study also aimed to determine whether specific indicators of financial stress differ according to smoking status. Adult clients seeking welfare assistance from two Social and Community Service Organisation sites in New South Wales, Australia, were invited to complete a cross-sectional survey between March 2012 and December 2013. Responses to a financial stress scale, smoking status and demographics were collected. Linear and logistic regression modelling was used to examine associations between smoking status and financial stress. A total of 1463 participants completed the survey. Current smokers had significantly higher total financial stress scores than ex-smokers and non-smokers respectively. Current smokers also had higher odds of severe financial stress indicators, such as going without meals (Odds Ratio = 2.2 and 2.0), than both non-smokers and ex-smokers. Even among a highly socioeconomically disadvantaged sample with high levels of financial stress, smoking status further exacerbates experiences of deprivation. Given the relationship between financial stress, socioeconomic disadvantage and difficulty quitting, it is important to provide enhanced cessation support to smokers experiencing financial stress.

The ‘price signal’ for health care is loud and clear: A cross-sectional study of self-reported access to health care by disadvantaged Australians

Objective: To describe self‐reported inability to access health care and factors associated with lack of access among a socioeconomically disadvantaged group.

Electronic nicotine devices considered through an equity lens

Keywords: Disadvantage; electronic cigarette; electronic nicotine devices (ENDs); equity; e-cigarette; equity; smokers

Self-Exempting Beliefs and Intention to Quit Smoking within a Socially Disadvantaged Australian Sample of Smokers

An investigation of beliefs used to rationalise smoking will have important implications for the content of anti-smoking programs targeted at socioeconomically disadvantaged groups, who show the lowest rates of cessation in the population. This study aimed to assess the types of self-exempting beliefs reported by a sample of socioeconomically disadvantaged smokers, and identify associations between these beliefs and other smoking-related factors with quit intentions. A cross-sectional survey was conducted from March–December 2012 with smokers seeking welfare assistance in New South Wales (NSW), Australia (n = 354; response rate 79%). Responses to a 16-item self-exempting beliefs scale and intention to quit, smoker identity, and enjoyment of smoking were assessed. Most participants earned <AUD

Smoking cessation intervention delivered by social service organisations for a diverse population of Australian disadvantaged smokers: A pragmatic randomised controlled trial

400/week (70%), and had not completed secondary schooling (64%). All “jungle” beliefs (normalising the dangers of smoking due to ubiquity of risk) and selected “skeptic” beliefs were endorsed by 25%–47% of the sample, indicating these smokers may not fully understand the extensive risks associated with smoking. Smokers with limited quit intentions held significantly stronger self-exempting beliefs than those contemplating or preparing to quit (all p < 0.01). After adjusting for smoking-related variables only “skeptic” beliefs were significantly associated with intention to quit (p = 0.02). Some of these beliefs are incorrect and could be addressed in anti-smoking campaigns.

Electronic cigarette use in New South Wales, Australia: reasons for use, place of purchase and use in enclosed and outdoor places.

OBJECTIVES There remains a need to identify effective smoking cessation interventions in severely disadvantaged populations. This trial aimed to examine the effectiveness of an intervention (Call it Quits) developed to promote smoking cessation and delivered by community social service case-workers. METHODS Call it Quits was a pragmatic, parallel randomised trial of a case-worker delivered smoking cessation intervention conducted in a non-government community social service organisation in New South Wales (NSW), Australia. Adult smokers requiring financial assistance were randomly assigned to the five-session Call it Quits intervention or usual care control group. Of the 618 eligible individuals, 300 were randomised to the intervention group, of whom 187 (62%) consented and 318 were randomised to the control group, of whom 244 (77%) consented, resulting in 431 participants. The primary outcome measure was self-reported continuous abstinence up to 6-month follow-up with biochemical verification. Primary analysis was performed using all the available data from participants under the assumption the data is missing completely at random, followed by sensitivity analyses. RESULTS No statistically significant differences in the primary outcome were found (1.4% in the control group versus 1.0% in the intervention group, OR = 0.77, p = 0.828). CONCLUSIONS A multi-component smoking cessation intervention delivering motivational interviewing-based counselling and free NRT by a trained case-worker within a community social service setting was not effective at achieving abstinence in a highly disadvantaged sample of smokers but increased attempts to stop and led to a reduction in number of cigarettes smoked daily.