What does it take to tackle inequalities in the burden of tobacco-related harm?

Healthcare organisations in the United States are being provided with tools for addressing health inequalities via the Roadmap to Reduce Disparities.

The roadmap is part of an initiative, launched by the Robert Wood Johnson Foundation in 2005, called Finding Answers: Disparities Research for Change.  As previously reported at Croakey, the roadmap recommends taking a structured approach to identifying and addressing inequalities.

When I wondered on Twitter recently whether any Australian health organisations were engaged in such work, Quit Victoria got in touch.

The article below describes some of the organisational, strategic, and cultural changes that have been part of Quit Victoria’s efforts to tackle inequalities in the burden of tobacco-related harm.

***

Taking a social justice approach to tackling tobacco

Jessica Craven writes:

In recent years, governments and health agencies have increasingly been looking at ways to address gaps in health and health care quality across racial, ethnic and socio-economic groups.

These disparities are particularly prevalent in the area of tobacco, with Australia’s most vulnerable groups suffering a greater burden of smoking-related death and disease.

This disparity in smoking rates is also linked to further disadvantage through financial hardship.

At Quit Victoria, we recently underwent a restructure to allow us to deliver on our strategic plan to reduce smoking prevalence amongst high smoking rate groups and hence reduce tobacco-related health and social and economic disparities.

Although we did not specifically use the Robert Wood Johnson Foundation’s Finding Disparities roadmap, we did follow many of the steps recommended when creating our strategy to develop interventions to address tobacco-related health disparities.

Recognise the disparities and committing to reducing them

Whole-of-population approaches – such as anti-smoking advertising campaigns, expansion of smoke free areas and cigarette price increases – have proved to be the biggest drivers of the decline in Australian smoking rates over the last 30 years.

We have seen smoking rates decline across all age and SES groups; however, smoking rates continue to remain very high amongst some of Australia’s most vulnerable groups, including people experiencing homelessness, Aboriginal and Torres Strait Islanders, and those suffering mental health illness or substance misuse problems.

Quitting smoking is a social justice issue because regular tobacco use amongst this vulnerable group can result in high levels of physical and psychological nicotine dependence and considerable social, emotional and financial stress as well as premature death.

These factors can prevent disadvantaged people from securing accommodation, food and employment, the building blocks to a fulfilling and healthy life.

Every Australian has the right to live free from smoking and the devastating diseases it causes.

During the development of Quit Victoria’s four-year strategic plan in 2011, it became clear that a new organisational model and strategy was necessary to meet our objectives.

At the core of the strategy is a commitment to reducing health disparities and improving social inclusion by partnering with social and community services to build their capacity to address smoking with their clients as part of their everyday work.

Implement a basic quality improvement structure and process

Our previous strategy focused on taking a broad approach to reach large numbers of health professionals providing once-off skill building in cessation support.

With our cessation training now being delivered widely online to health professionals and most health settings now smoke-free, we needed to focus our efforts into new areas.

A need for new operating model and organisational structure was identified to provide deeper support in policy and practice in targeted settings and locations and include evaluation and continuous improvement.

This would allow for innovation and evidence to support program design, review of programs and dissemination of outcomes.

We have now hired a Research and Evaluation co-ordinator and an evaluation officer to support these measures.

Equity as an integral component of quality improvement efforts

Focusing on equity is an important part of improving our services to marginalised groups including the Aboriginal Quitline Enhancement service.

Aboriginal and or Torres Strait Islander Australians are more than twice as likely to smoke as the general population and one in five Aboriginal and or Torres Strait Islander deaths are due to tobacco use.

Despite this, Quitline has historically had low volumes of calls from Aboriginal and or Torres Strait Islanders.

Aboriginal Australians’ understandings of health differ from those of the general population, and these need to be taken into account when providing services.

For this reason, Quitline now has dedicated Aboriginal counsellors who use narrative counselling techniques and approach health with an understanding of the historical, social and cultural factors still impacting on Aboriginal health and wellbeing.

Working with our partners to address issues which contribute to the disparity and outcomes for different populations will be an essential part of reaching our goal of reducing high smoking rates in these populations.

Designing effective interventions with partners

The Tobacco Action Project, a collaborative initiative with the Royal District Nursing Service (RDNS), is one of the first interventions to come out of our new partnership approach.

The project aims to provide homeless clients of the Royal District Nursing Service Homeless Persons Program in Victoria with tailored support to cut down or quit smoking as well as gain an understanding of current smoking prevalence within this group.

Participants of this initiative are offered weekly one-on-one smoking cessation appointments with a nurse as well as free smoking cessation pharmacotherapy (such as patches or quitting medications) for up to 12 weeks.

Participants are also offered access to Quitline for telephone smoking cessation support, including the call back service as well as free mobile phones and credit.

A commonly held myth is that marginalised groups are not interested in addressing their smoking.

However, a high level of activity to reduce smoking was found with almost two-thirds of smokers reporting they had made an attempt to cut down or quit within the previous three months.

More than half of respondents said they would like to stop smoking and the audit found desire to stop smoking was unrelated to whether their circumstances were categorised as primary, secondary or tertiary homelessness.

Implement, evaluate and refine the intervention

The project began in April 2011 and final evaluation findings will be available in mid-2013.

However, the program has already produced promising outcomes for clients.

One participant had saved $400 after being quit a month and was very proud to have more money to spend on food.

Just by cutting down her tobacco use, another participant has finally been able to cease her regular visits to her local hospital leg ulcer clinic, an unexpected benefit, which is motivating her to give up the habit completely.

Sustain the intervention

Quit Victoria and RDNS are optimistic this project will not only have successful outcomes for homeless people but will also inform similar service providers about new ways of working together with clients to reduce tobacco use.

Challenges and barriers

The transition to our new partnership approach has not been without its challenges.

Often those working in the community sector are reluctant to address smoking with their clients in favour of addressing more immediate health concerns.

Many believe their clients do not have the desire nor the capacity to quit smoking and are therefore unwilling to address it with them.

We believe everyone has the right to be asked about their smoking and be supported to quit.

However, the evidence has shown that clients do want to quit and that sometimes, health professionals act as a gatekeeper when it comes to their clients.

Those working in the sector do have lots of competing issues when it comes to their clients and the focus has been on showing health workers how brief cessation interventions can be built into routine casework practice.

Cancer Council NSW’s Tackling Tobacco Program found many staff in the social services sector changed their minds about providing cessation support to their clients.

In the majority of cases, projects that provided direct cessation support found that clients were interested in quitting.

Some project staff were surprised at the level of interest and had to review their own ideas and assumptions as a result.

Where they had had hesitations about the value and relevance of addressing tobacco issues, they now became more enthusiastic about providing smoking care.

Building knowledge and capacity within our organisation and adjusting resources to reflect varying levels of health literacy have also been barriers we have had to overcome as we continue to improve and refine our efforts.

Future work

Reducing tobacco related health disparities will require a combination of sustained population wide strategies and additional targeted support to maximise reach among disadvantaged groups.

This involves applying the best of what we currently know to high smoking rate populations whilst being open to and exploring the effectiveness of new strategies delivered within compassionate and supportive environments where people are already receiving support.

Sharing knowledge and experiences with other health organisations and service providers facing similar challenges will be a key part of ensuring we meet our goal of reducing tobacco-related health disparities.

• Jessica Craven is media relations coordinator for Quit Victoria

***

PS: You can follow Finding Answers: Disparities Research for Change on Twitter

Croakey is keen to hear from other organisations and services that are taking a structured approach to addressing health inequalities. Share your story here…