Having a yarn about smoking: Using action research to develop a ‘no smoking’ policy within an Aboriginal Health Organisation

Health Policy 103 (2011) 92–97

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Having a yarn about smoking: Using action research to develop a ‘no smoking’ policy within an Aboriginal Health Organisation Gillian Fletcher a,∗ , Bronwyn Fredericks b,d , Karen Adams c , Summer Finlay c , Simone Andy c , Lyn Briggs c , Robert Hall d a b c d

Australian Research Centre in Sex, Health and Society, La Trobe University, 215 Franklin Street, Melbourne, Victoria 3058, Australia Queensland University of Technology, QUT, 2 George St, Brisbane, Queensland 4000, Australia Victorian Aboriginal Controlled Community Health Organisation (VACCHO), 5–7 Smith Street, Fitzroy, Victoria 3065, Australia Department of Epidemiology and Preventive Medicine, Monash University, Victoria 3800, Australia

a r t i c l e Keywords: Aboriginal Smoking Policy development Action research

i n f o

a b s t r a c t Objectives: This article reports on a culturally appropriate process of development of a smoke-free workplace policy within the peak Aboriginal Controlled Community Health Organisation in Victoria, Australia. Smoking is acknowledged as being responsible for at least 20% of all deaths in Aboriginal communities in Australia, and many Aboriginal health workers smoke. Methods: The smoke-free workplace policy was developed using the iterative, discursive and experience-based methodology of Participatory Action Research, combined with the culturally embedded concept of ‘having a yarn’. Results: Staff members initially identified smoking as a topic to be avoided within workplace discussions. This was due, in part, to grief (everyone had suffered a smoking-related bereavement). Further, there was anxiety that discussing smoking would result in culturally difficult conflict. The use of yarning opened up a safe space for discussion and debate, enabling development of a policy that was accepted across the organisation. Conclusions: Within Aboriginal organisations, it is not sufficient to focus on the outcomes of policy development. Rather, due attention must be paid to the process employed in development of policy, particularly when that policy is directly related to an emotionally and communally weighted topic such as smoking. © 2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Cigarette smoking is responsible for at least 20% of all deaths in Aboriginal communities in Australia [1]. As noted in the National Aboriginal and Torres Strait Islander Health Survey, 2004–2005, Aboriginal people are more than twice as likely to smoke than non-Aboriginal people in Australia [2]. Gender- and age-adjusted data from the 2002 National

∗ Corresponding author. E-mail addresses: g.fl[email protected] (G. Fletcher), [email protected] (B. Fredericks), [email protected] (K. Adams). 0168-8510/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2011.06.014

Aboriginal and Torres Strait Islander Social Survey indicates that 53.5% of Aboriginal Victorians aged over 15 are current smokers [3]. In contrast, just 19.2% of Victorian adults were regular smokers in 2002 [4]. While Aboriginal women are more likely than Aboriginal men to be non-smokers and to have never smoked [3], Aboriginal women are 2.5 times more likely to smoke than non-Aboriginal women [5]. Smoking within Aboriginal communities exists within a complex web in which the lived effects of colonisation combine with long-term socio-economic disadvantage and the recent normalisation of smoking as communal activity. As noted by van der Sterren et al., ‘In community consultations conducted in 2000–2001 for the National Aboriginal and Torres Strait Islander Tobacco Control Project,

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smoking was seen as a mechanism to maintain kinship bonds, a sense of belonging and social cohesiveness. Exchange relationships were seen to be maintained and enhanced through the sharing of cigarettes and information in a social forum’ [6, p. 5]. In addition Aboriginal Controlled Community Health Organisations (ACCHOs) – which provide community health care in the metropolitan, regional, rural and remote areas of all States and Territories in Australia and are controlled by, and accountable to, Aboriginal people – face particular barriers to implementing smoke-free workplace policies. These barriers include confusion over where to physically place the approximate 50% of clientele and staff who smoke, poor signage, and how to move smokers away from buildings without jeopardising their access to services [7]. As long ago as 1990, it was acknowledged that Aboriginal Health Workers – who provide primary health care services and are the first point of contact for many patients at an Aboriginal medical service – and community members should be directly involved in development of smoking cessation programs, in recognition of the particular complexities of smoking within Aboriginal communities [8]. Yet in 2008, the Centre for Excellence in Indigenous Tobacco Control (CEITC) reported that ‘there is poor understanding of what motivates Aboriginal people to take up smoking, or to quit and stay quit’ [1, p. 1]. Further, in an evaluation of the pilot phase of a tobacco brief intervention program in three Aboriginal health care settings in rural and remote north Queensland, Harvey et al. found that while Aboriginal health care workers are crucial stakeholders in the drive to reduce smoking-related deaths within Aboriginal communities, there was a ‘frustration and [a] sense of fatalism among health staff regarding their ability to effect behaviour change through smoking cessation advice’ [9, p. 426, 430]. Current support for health care workers in promotion of smoking cessation does little to acknowledge or respond to the central role played by the social environment and the influences of social networks on smoking patterns within Aboriginal communities [1,10]. In addition, there did not seem to be recognition that Aboriginal health services are themselves social environments where smoking is often seen as a communal activity. VACCHO is the peak Aboriginal health body representing 24 Aboriginal Community Controlled Health Organisations (ACCHOs) in the State of Victoria, Australia. Its key role is to ‘build the capacity of its membership and to advocate for issues on their behalf’ [11]. The Goreen Narrkwarren Ngrn-toura – Healthy Family Air project, implemented by VACCHO and funded by the Victorian Department of Health, was established in 2009 with the aims of: (1) developing, implementing and evaluating a multifaceted holistic intervention aimed to reduce smoking among Aboriginal pregnant women and carers of young children; and (2) increasing understanding and knowledge of how to best support Aboriginal communities to reduce smoking among pregnant women and carers of young children. This article will focus on one aspect of the project: development of a Smoke-free Workplace Policy within VACCHO itself. When the Goreen Narrkwarren Ngrn-toura – Healthy Family Air project began, VACCHO did not have a stand-

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alone smoking policy but only addressed smoking within its Occupational Health and Safety Policy (OH&S). Under the OH&S policy, the focus was on compliance to statutory duties to the Victorian and Federal Governments. Few staff members were aware of this policy element. The building from which VACCHO operates was smoke-free, and staff members who felt the need to smoke during work hours would do so by the back door, directly beneath the building’s ventilation shaft. 2. Methods The Goreen Narrkwarren Ngrn-toura – Healthy Family Air project is designed to work with three intersecting groups: (1) pregnant women and people who care for children under the age of five (this could include partners, grandparents, siblings of the mother and father and friends). (2) Aboriginal Health Workers (AHWs), Koori Maternity Strategy Workers and In-Home Support Workers, all of whom are both community members and community-based professionals. (3) ACCHOs, which are themselves communities of Aboriginal service providers, who live and work within the broader Aboriginal community. Participatory Action Research (PAR) was chosen as the over-arching project methodology because of its proven effectiveness and acceptability within Aboriginal communities, both in Australia and elsewhere. Within the project, this methodology was implemented using the Aboriginalspecific concept of ‘yarning’. Yarning is described by Bessarab and Ng’andu as ‘an Indigenous cultural form of conversation’ [25, p. 37]. ‘Yarning is a process that requires the researcher to develop and build a relationship that is accountable to Indigenous people participating in the research’ [25, p. 38]. A key feature of yarning is that conversations are allowed to develop (as far as possible) without the use of direct questions. A topic is introduced in a deliberately open manner, and the yarning participants can then take that topic and respond as they see fit, rather than feeling that they are being interviewed or formally questioned. The project team felt that yarning and PAR have the same paradigmatic and methodological roots, in that both develop active engagement in reciprocal relationships of information-sharing. This active engagement was achieved through yarning undertaken in corridors, during chance encounters in the kitchen, and in areas of VACCHO where smokers gather, as well as in informal, open meetings. Throughout, health workers were encouraged to identify, and reflect on, their lived experience of issues related to smoking – both as professionals expected to support smoking cessation and as community members with social relationships in which smoking plays a complex role. As noted by Canadian researchers Fletcher et al. [12, p. 10]: Interventions involving Aboriginal community members as active collaborative partners produced better results than interventions that involved community members only as consultants. These results were significant for sustainability, capacity building, and positive health outcomes.

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Fig. 1. Participatory action research cycle, as represented by Wadsworth.

Within Australia, PAR has been repeatedly recommended as a culturally sensitive model for Aboriginal research [13–18]. The Royal Commission into Aboriginal Deaths in Custody report recognised PAR as the most appropriate model for evaluation of Aboriginal health care services [19] and, further, the report’s recommendations stated that research into health concerns should involve Aboriginal people at both the development and implementation stages [15]. PAR offers scope for ‘researching back’ by Aboriginal people as resistance to the sense of ongoing colonisation embedded in so much traditional research [20, p. 7]. Key to arguments for PAR within Aboriginal communities has been the tenet defined by Anderson (and cited in Humphery [21]) that it is the researched. . . who should be the primary beneficiaries of any inquiry’ [21, p. 201, author’s emphasis]. This is also in line with the values of integrity, reciprocity, respect, equality and responsibility, defined within the National Health and Medical Research Council’s Values and Ethics: Guidelines for Ethical Conduct in Aboriginal and Torres Strait Islander Research [22]. The Guidelines themselves were developed through a collaborative process overseen by a Working Party of researchers, Aboriginal community controlled health sector representatives, Human Research Ethics Committee representatives and policy makers. Reason and Bradbury argue that, at its core, action research involves the bringing together of ‘action and reflection, theory and practice, in participation with others, in the pursuit of practical solutions to issues of pressing concern to people’. [23, p. 1]. This is also coherent with Rigney’s work on anticolonial research [17]. The Goreen Narrkwarren Ngrn-toura – Healthy Family Air project adopted a PAR approach best described by the following, iterative cycle as represented by Wadsworth [24] (Fig. 1). Early-stage, informal yarns were held between the Project Officer, Summer Finlay, and VACCHO staff members (smokers and non-smokers) in order to begin to create a culture in which smoking could be discussed. As will be explained in Section 3, smoking, and smoking cessation, are seen as sensitive topics among AHWs. Two initial ‘let’s yarn about smoking’ drop-in sessions were organised, and all staff members invited to attend for some or all of the session as they saw fit. A further two ‘let’s yarn about smoking’ sessions were held specifically for managers, once a draft policy had been developed. These sessions focused on managers’ responses to the draft policy, and their concerns and ideas regarding policy implementation. The informal nature of all four sessions meant that staff members were not required to sign-in, but project team

meeting records show that approximately 40% of all VACCHO staff members participated in one or more of these sessions. The project team kept their own notes of each of these meetings, and during brainstorming (facilitated by the project team) key points were noted on flipchart paper then reviewed, revised as appropriate then agreed by everyone present. Notes from each meeting were then circulated through the internal email system, ensuing that anyone who did not attend a meeting still had an opportunity to contribute to the debate through face-to-face discussion with the Project Officer or through email. In addition to the yarns described above, all staff members were invited to participate in an anonymous, online survey, with two-thirds of all VACCHO employees (31) responding. PAR iterations occurred throughout the process of policy development, in that within each ‘let’s yarn about smoking’ session participants were encouraged to share their experiences related to the policy development process in particular and to smoking or smoking cessation in general. They were also asked to reflect on the broader socio-cultural and institutional relevance of these experiences, and to participate in planning next steps. Further, the Smoke-free Workplace Policy developed as a result of the process reported in this paper will itself be subject to iteration, in that the proposal is that it will be reviewed and amended (as required) through future VACCHO yarns. 3. Results and discussion When the Project Officer began yarning with VACCHO staff members in relation to smoking and the possibility of developing a specific VACCHO Smoke-free Workplace Policy, she noted that time and again people expressed concern regarding talking about smoking, and in particular talking about smoking by staff members. It was considered a topic that carried the risk of creating friction and disagreement within the VACCHO community. Fears of friction were also discussed during the first open session yarn held at VACCHO. In addition, the topic was one closely (and personally) associated with grief and bereavement for staff members. Everyone present at the first VACCHO staff yarn about smoking reported having lost a family member or friend to smoking-related illness. People spoke about attending funerals on a regular basis – sometimes even attending more than one funeral in the same week – and it was recognised that the communal nature of such events, combined with grief and stress, increased the likelihood of people smoking. Smokers also admitted that feeling judged by others made them anxious. One woman said: ‘My daughter told me I couldn’t pick up her new baby unless I washed my hands, because I was smoking. The stress just made me smoke more’. Non-smokers admitted that they often felt unable to express how they felt in case someone was offended. Some non-smokers also reported feeling ‘left out’ because they did not smoke – the issue of work-related discussions being carried out at the ‘back door’ during smoking breaks was raised more than once. Several staff members shared their own personal stories of reducing or stopping smoking. For one, the experience of seeing and hearing community Elders who were reliant

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on oxygen tanks talk about the effect of smoking on their lives had a major impact. For another, inspiration came in the form of VACCHO CEO Jill Gallagher, who began smoking at the age of about seven and smoked through the deaths from lung cancer of her two sisters before succeeding in quitting smoking. This story was commonly known within VACCHO, and has also been reported in press [26]. ‘I thought to myself, “if Jill can do it so can I”’, the staff member said. One staff member who had managed to considerably reduce the amount he smoked told the meeting he made it a point of pride not to smoke while working, because ‘we are supposed to be the peak body, we have to set an example’. As previously noted, all staff members were also invited to participate in an anonymous, online survey. Of the 31 responders, eight smoked daily and two smoked less regularly. Just 12 of the 31 were aware that VACCHO had any form of policy position on smoking (under the OH&S policy). Every survey respondent, smoker or not, agreed that VACCHO should support staff members who wanted to quit. The survey also provided respondents with open questions, where they could add any further thoughts about smoking in general or about development of a Smoke-free Workplace Policy in particular. Results of the survey were shared with all staff, and another yarn held so that staff members could consider what a VACCHO Smoke-free Workplace Policy could (and should) include. (The survey methods and results will be published elsewhere.) This yarn was supported by a comparison of policies in place within three ACCHOs and of the draft policies promoted by smoking cessation organisation QUIT within two Australian States. The comparison was developed by the Project Officer, drawing on advice from VACCHO staff members as to which ACCHOs were known to be particularly active in encouraging staff members to quit smoking. In an ideal PAR process, staff members, working in collaboration with the Project Officer, would have developed this comparison. The reality, however, was that VACCHO staff members had limited time to give to the project and the decision was taken to use that time in yarning about experiences and ideas related to policy development, rather than in the comparison work which required no sharing of experience. The comparison covered eight key no-smoking policy elements: (1) policy rationale; (2) whether or not no smoking areas were designated; (3) whether or not there was a designated smoking area; (4) support for staff members wishing to quit smoking; (5) policy enforcement; (6) whether or not staff members are required no to smoke with clients; (7) whether or not a review period was built in to the policy; and (8) whether or not a policy contact person was identified. The comparison results were as follows (ACCHO names have been removed for purposes of confidentiality) (Fig. 2). Using the comparison as a starting point for a yarn on what a VACCHO policy could include, it was generally agreed that any policy needed to start with a clear rationale. As one person said, ‘we need to talk about why we are doing this; smoking is killing our mob, and this is part of trying to change that’. People also felt strongly that although this was going to be an official policy, the wording used

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should be as informal as possible in order to help ensure ownership of the policy and as a way of demonstrating that the policy was primarily developed to save Aboriginal lives and improve Aboriginal health, and that procedural, legislative concerns were secondary. Where possible, the wording of the final policy drew on the phrases or emotions expressed by staff members in their responses to the open questions in the staff survey. Under a heading ‘Why does VACCHO need a smoking policy?’ the final document states: Smoking is the principal contributing factor to the majority of preventable life-shortening health conditions in the Aboriginal community, including cardiovascular disease, cancer and other illness associated with diabetes. As the peak representative body for Aboriginal Community Controlled Health Services in Victoria, VACCHO has the responsibility to model actions that reduce the effect of smoking on people’s health. [27] At the yarn on policy comparisons, it was agreed that smoking should be banned within all VACCHO buildings and vehicles, and within three meters of air vents or within three meters of all entrances and exits. Concern expressed about the social and cultural challenges of not being able to smoke with community members was raised, and in recognition of the very real social and cultural intersections between smoking and Aboriginal communality, the final policy states: ‘Staff are encouraged to refrain from smoking with visitors or stakeholders while conducting VACCHO business. Staff are expected to demonstrate that they understand the need to set an example for the community and our partner organisations.’ [27] Throughout the yarns about smoking held within VACCHO, consistent concern was expressed that those staff members who wanted to give up should receive support. This was reflected in the final policy document, which has a discrete section on assistance to staff. The section begins with the statement: ‘VACCHO recognises that smoking is an addiction’, and acknowledged the ‘complex nature’ of that addiction. [27] Support offered is as follows: • One-on-one sessions with a QUIT educator during work time. • Up to three sessions with a hypnotherapist. • Mentoring (time to speak to a nominated ex-smoker who can mentor you while you are giving up). • Peer support (time to speak to other staff who are giving up). • Time during work to seek medical advice about quitting smoking. In addition, the policy states that support for other methods of quitting will be considered. The policy is linked to VACCHO’s existing Disciplinary Policy, and identifies the responsibilities both of VACCHO and of staff members. VACCHO is to be held responsible for placing appropriate signage throughout the workplace; stating that VACCHO is a smoke-free workplace or, in the interim, ‘moving towards a smoke-free workplace’ in all job

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ACCHO 1

Rationale for policy? Smoking banned in certain areas?

• Cars • In the buildings • Anywhere that is not the designated smoking area

ACCHO 2

ACCHO 3

x

x

• Cars • In the buildings • Anywhere that is not the designated smoking area

Designated smoking area?

• Cars • In the buildings • Anywhere that is not the designated smoking area

Quit draft policy (State 1)

Left open to each organisation

x

Support staff to quit?

x

Enforcement of policy?

x

Staff are not to smoke with clients Policy is reviewed periodically

x

Nominated person for staff to contact if they would like to discuss the policy

x

x

x x

6 months

OHS representative

As per the workplace discipline policy

x

OHS representative

Quit draft policy (State 2)

Left open to each organisation

Left open to each organisation

Left open to each organisation

Left open to each organisation

Left open to each organisation

As per the workplace discipline policy

As per the workplace discipline policy

x

x

Left open to each organisation

Left open to each organisation

OHS representative

OHS representative

Fig. 2. Policy comparison table.

advertisements; ensuring that all staff have equal opportunity to access smoking cessation support; ensuring that all official VACCHO social events will be smoke-free; ensuring that potential mentors are available, and supported in mentoring people who are quitting; making literature on smoking, and quitting, available to all staff. Staff members are held responsible for adhering to the Smoke-free Workplace Policy. The policy was officially adopted by the VACCHO Board and implemented from July 1, 2010. A review, carried out through yarning, was initially planned for September 2010 but VACCHO managers suggested that the policy should be given one year to ‘bed in’. It was agreed to carry out a participatory review of the policy on an annual basis.

4. Conclusion Health policy does not and cannot exist outside of history or outside of cultural politics. The same is true of the processes of development of health policy. While VACCHO had fulfilled its statutory duties in relation to policy by incorporating reference to smoking within its OH&S Policy the reality was, first, that few staff members were aware of this and, second, the policy was seen predominantly as fulfilling a procedural function and not as a living document. Smoking was seen as a topic that was socially and culturally difficult to discuss, because of the risk of conflict and of loss of face. Further, as shown by the research from Queensland cited in the Introduction to this article, the level of smokingrelated deaths and illnesses within Aboriginal community

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is such that many Aboriginal Health Workers feel a sense of fatalism [9]. By utilising the culturally appropriate (and complementary) methodologies of PAR and yarning, the Goreen Narrkwarren Ngrn-toura – Healthy Family Air Project team were able to engage VACCHO staff members in yarns about smoking, the emotional impact of smoking (and smoking cessation work) and development of a Smoke-free Workplace Policy. Use of an all-staff survey with both open and closed questions ensured that those staff members who did not attend yarns were still able to put their views forward. It is important to emphasise that the steps in the process reported here are not intended as a ‘template’, for imposition at other Aboriginal organisations. Rather, this article is an indication of what can be achieved when a flexible, responsive and culturally appropriate process to policy development is adopted. Indeed, adoption of this process is almost certain to lead to the development of different steps within different organisations. The scheduled review of the VACCHO policy will provide the project team with a valuable opportunity to keep yarning about smoking with that organisation, and will allow staff members to once again express their feelings and opinions. Whatever the outcomes of the policy review, the policy development process has already proved Bessarab and Ng’andu’s assertion that ‘collaborative [yarning has] the potential to transform the way in which people approach a project and/or their work’ [25, p. 41].

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Acknowledgements The Goreen Narrkwarren Ngrn-toura – Healthy Family Air project is implemented with funding from the former Victorian Department of Human Services (now Department of Health), Government of Victoria.

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