Smoking is a highly significant health issue in Aboriginal Communities in New South Wales (NSW). Smoking prevalence estimates of more than 50% have been repeatedly reported for Aboriginal populations, more than double those of non-Aboriginal groups. In the general Australian population, reductions in smoking prevalence have been demonstrable over the last decade, whereas these measures for Aboriginal people have remained constant (ABS 2005). Higher rates of smoking-related disease, hospitalisation and death have been documented for Aboriginal people including associated with respiratory disease, lung cancer, cardiovascular disease, and low birth weight babies (NSW Tobacco Action Plan 2005-2009).

Despite this high burden of disease, health service and research responses to the issue of smoking for Aboriginal people to date have tended to be small scale, short term, piecemeal and uncoordinated, and few research projects have evaluated interventions. Project Team Members have been involved in a significant proportion of tobacco control intervention studies already reported. Studies undertaken by Dr Rowena Ivers evaluated a range of community based tobacco control interventions in remote Aboriginal community settings in northern Australia. Andrew Mark and others from the National Heart Foundation and local Aboriginal communities implemented and evaluated a program focused on a quit group for Aboriginal Health Workers in the Illawarra region of NSW. A randomised controlled trial, led by Professor Sandra Eades, is currently evaluating a culturally-specific smoking cessation intervention aimed at pregnant Aboriginal women in several Australian sites. In addition, a recent national audit review of Indigenous tobacco control initiatives concluded with recommendations for accredited training for Aboriginal Health Workers, professional development in Indigenous tobacco control and, improved access to nicotine replacement therapies.

In New South Wales, the Australian State with the largest number of Aboriginal people, there is very limited locally generated evidence on which to base smoking cessation and tobacco control policy and practice for Aboriginal communities. This project will make some progress towards addressing this large gap, by developing, implementing and evaluating a coordinated approach to enhancing smoking cessation and tobacco control activities in six NSW Aboriginal communities, facilitated through a dedicated specialist Tobacco Control Worker and other activities based at Aboriginal Community Controlled Health Services (ACCHSs). The project has been designed to complement, and be coordinated with, planned NSW Health activities around smoking cessation and tobacco control in Aboriginal communities. As part of the NSW Tobacco Action Plan 2005-2009, NSW Health plans to implement and evaluate activities including "SmokeCheck", a program focused on training Aboriginal Health Workers in a range of health care settings around NSW, and another program of accredited competency based training in smoking cessation accessible to mainstream health care providers.

Main objectives

The project aims to reduce smoking-related disease and morbidity for Aboriginal people in NSW communities.

Specific objectives of the project are to:

• trial an innovative tobacco control and smoking cessation program in a range of ACCHS settings involving a dedicated specialist Tobacco Control Worker and a coordinated program of enhanced support;
• increase the capacity of ACCHSs and their staff to deliver smoking cessation interventions to Aboriginal people in NSW communities (including through brief interventions, quit groups and increased access to affordable nicotine replacement therapies) and to implement and facilitate tobacco control activities;
• increase readiness to quit, number of quit attempts, and successful quit attempts amongst Aboriginal people in NSW communities;
• contribute to the evidence base about smoking issues and interventions in an Aboriginal Community context;
• develop a smoking cessation and tobacco control program that is sustainable and transferable.

The project incorporates the principles of Aboriginal self-determination and community development including capacity building, community involvement, community empowerment, ownership and equity.

The research team

The project is a collaboration between the Aboriginal Health and Medical Research Council of New South Wales (AH&MRC), 12 individual ACCHSs from across NSW, the Collaborative Centre for Aboriginal Health Promotion (CCAHP), the National Heart Foundation, NSW Health Department, and the Sax Institute.

The research team will be led jointly by Dr Jenny Hunt, Medical Policy Officer, AH&MRC and James Ward, Acting Director CCAHP. Dr Hunt is a public health physician who has worked in Aboriginal health for 15 years, including in public health, research and clinical practice at ACCHSs around Australia. Mr Ward has significant experience in managing a range of public health initiatives including workforce and program development, in the fields of drug and alcohol, harm minimisation, sexual health and blood borne viruses.

Others in the team include:

• Professor Sandra Eades (Senior Research Fellow, Sax Institute), an acknowledged Australian leader in Indigenous health research, who has specific expertise in child health and smoking research areas, as well as in developing and implementing collaborative research with Aboriginal communities.
• Dr Rowena Ivers, a public health physician and general practitioner who has worked in Aboriginal health for 15 years. Dr Ivers has led a range of nationally recognised research projects about tobacco control and smoking cessation in Aboriginal community settings.
• Mr Andrew Mark (Regional Health Promotion Coordinator, National Heart Foundation of Australia), who has worked on tobacco cessation with Aboriginal communities since 2000, in particular implementing and evaluating smoking cessation programs for Aboriginal people in the Illawarra region.
• Ms Elayne Mitchell (Senior Policy Analyst (Cessation), Tobacco and Health Branch, NSW Health), who has been working in workforce development in tobacco and alcohol brief intervention since 1993, and has delivered training in evidence based smoking cessation in Aboriginal community settings to pilot materials for the SmokeCheck project since 2003. Her role will ensure the proposed project's activities and planned NSW Health activity in smoking cessation and tobacco control are complementary and coordinated.

Twelve NSW Aboriginal Community Controlled Health Services (ACCHS) will also be partners to the project. ACCHSs are governed by local Aboriginal Community leaders, are critical to the delivery of primary health care to Aboriginal community members, and are seen as a focal point for Aboriginal communities.

Methodology

The proposed research methodology is a community-randomised controlled trial, with six ACCHSs being randomly allocated to receive the intervention and six ACCHSs acting as control sites. ACCHSs will be selected based on interest and capacity, to give a mix of urban, rural and remote locations throughout NSW.

The intervention will be multi-faceted, community-based, and ACCHS-led, and includes recruiting, training and supporting an Aboriginal Health Worker (AHW) to work in the role of a specialist dedicated Tobacco Control Worker. Support will include: information about evidence-based practice and models of best practice in tobacco control and smoking cessation relevant to an Aboriginal community context; access to formal training; and the setting up of a network between Tobacco Control Workers in intervention sites. In developing local community-based health promotion initiatives, the Tobacco Control Workers will be encouraged and supported to: draw on existing evidence about programs in an Aboriginal community context; be innovative; develop and build on links/partnerships with local community organisations and groups; and seek supplementary funding opportunities.

Comprehensive process and impact evaluation of local tobacco control activities and health promotion initiatives and quit groups, as well as evaluation of the intervention as a whole will be undertaken.

The described approach is appropriate for addressing the project's objectives because it combines Aboriginal Community control with an evidence-based approach, a focus on capacity building and sustainability, and methodological rigour in evaluating the effectiveness of interventions likely to improve the health of Aboriginal people. Aboriginal community control for this project is facilitated through intervention sites being located at ACCHSs throughout NSW, and through the lead role of the AH&MRC. Involvement of the Aboriginal community members on the AH&MRC Board and at ACCHSs, the establishment of a Community Advisory Group for the project, and the inclusion of Aboriginal people as key members of the project team will ensure that all phases of the project are guided by the expertise and perspectives of Aboriginal people.

ARC conducts international project work in the Western Pacific region, with a focus on nurse training.

In 2006 the Centers for Disease Control and Prevention (CDC) invited the Australian Respiratory Council (ARC) to participate in development of educational materials and to undertake training in tuberculosis case management for nurses from the USA Pacific Islands (USAPIs) at the 4th Annual US Pacific Islands Regional Tuberculosis Workshop held in Honolulu, Hawai'i from 28 November to 2 December 2006.

Prior to the training course, the program and teaching materials were developed by a technical working group consisting of representatives from the US National TB Controllers Association (NTCA), CDC, Secretariat of the Pacific Community (SPC) and ARC.

The 5-day workshop, which has been an annual event since 2003, was attended by 100 participants and included three concurrent training courses: one for clinicians, one for laboratory technicians and the nurses training in tuberculosis case management.

The nurses training was carried out by the following:

• Ms Pam Banner from ARC;
• Ms Amanda Christensen from ARC; and
• Ms Carol Pozsik from the NTCA in Atlanta, Georgia.

Twenty-one participants from six countries participated in the nursing course. The countries that the nurses represented were; Pilau, Marshall Islands, Guam, The Federated States of Micronesia (Yap, Pohnpei, Kosrae, Chuuk), Commonwealth of the Northern Mariana Islands and American Samoa.

Participants were either nurses or DOTS workers with differing levels of experience and knowledge.  The group was enthusiastic and eager to learn, this being the first occasion when nurses had a dedicated training session as part of the PITCA forum. Participants interacted well with each other and with faculty members and did not hesitate to ask questions and challenge the trainers.

The overall objective for the training course was to provide information on the use of a case management framework for TB Control within USAPIs.

Methods of instruction included PowerPoint presentations, discussions, clinical demonstrations and practical exercises. The faculty involved and encouraged participants to share their experiences and to identify local solutions from their collective nursing experiences and expertise.

The participants enthusiastically shared their experiences, knowledge and skills.  It was noted in the evaluations that the sharing of local information was an important aspect of the training.

When the participants completed an evaluation form, it was particularly satisfying to learn that 20/21 of the participants commented that they gained new skills/knowledge that will improve the way they work.

From the participants' assessment, evaluation of training program and the trainers' observation the participants seemed to both enjoy and find the training a valuable experience.  Collectively, there is an enormous amount of skill and expertise within the nurses working in the USAPIs and an enthusiasm for learning about each other's work and role.  The opportunity for these nurses to meet was very much valued by all participants.

Importantly, comments were made by a number of participants that part of the success of the training was that nurses were delivering the training for nurses.  We each understood the others perspective and frame of reference which seemed to minimize any barriers for participation and involvement.  It was a pleasure to work with such a group of committed and dedicated health professionals.

In addition to the relationships developed with the project partners, of additional benefit to the faculty was the opportunity to meet with nursing, medical and laboratory staff from the USAPI.  This invaluable opportunity enabled us to better understand the clinical, cultural and program structures within this region and apply this knowledge to clients within our respective services given the movement and migration patterns seen in our world today.

As part of the Pacific Regional Tuberculosis Control Project of the Secretariat of the Pacific Community (SPC), the Australian Respiratory Council (ARC) has provided technical support for the laboratory service supporting the National Tuberculosis Program (NTP) in Samoa since 2001, including a training course conducted in 2002 and the facilitation of an external quality assessment (EQA) program for the laboratory.

Laboratory Consultant Ms Kay Withnall has visited the Tupua Tamasese Meaole (TTM) Hospital laboratory, the laboratory serving the NTP in Samoa, on three occasions since 2001.

The most recent visit, undertaken from 23-27 October 2006 provided culturally and technically appropriate training in TB diagnosis to laboratory technicians at the TTM Hospital. In addition, an on-site evaluation of the laboratory service was conducted.

The training course was successful with the keenness and interest of all six students being reflected in their excellent results. The average result for the written test was 94% and for the microscopy test 98%.