Reviewer's report
Title:"Its almost expected": rural Australian Aboriginal women's reflections on
smoking initiation and maintenance: a qualitative study
Version: 3Date:16 September 2011
Reviewer: Annette Schultz
Reviewer's report:
REPORT For: “It’s almost expected”: rural Australian women’s reflections on
smoking initiation and maintenance; a qualitative study
Review completed by Dr. Annette Schultz September 16, 2011
Reviewer's report
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I acknowledge the authors efforts in addressing previous reviewer comments,
which has lead to an improved manuscript. At this time most of my comments are
minor with a few exceptions. I acknowledge my reviewer comments do not fit into
the suggested template. While some comments are minor changes, others will
require rethinking before revising. Finally, I believe they are all required to
strengthen this interesting and important manuscript.
Background section is great and flows well. No other comments
Methods:
1) my main concern here is the lack of reference concerning the qualitative
approach used, which includes sampling and data analysis section…who was
read to inform this study? There is mention of purposive sampling strategy but no
reference? The two references within this section make sense but neither has
anything to do with qualitative approaches.
2) I suggest deleting third sentence within the first paragraph of this section
(Other papers related…) as it is not necessary and unless there are actual
manuscripts that you reference this is not appropriate. I can imagine future
readers that enjoy this manuscript will search for other articles authored by you.
3) I also wondered if there was a way to move the sentences about SCT
informing the study into the first paragraph. In addition, I am also curious about
why this theory is including here. Although the authors stated it was used to
guide data analysis…I see no evidence of the analysis influence in the results or
in the discussion sections. Am not sure how to guide and there are at least two
options: 1) let this go within the method sections or 2) make some shifts in the
other two. Having said this, below you will notice that I really like the organization
and flow of the results and discussion.
Data collection:
4) I remain curious why both were used focus groups and individual interviews. I
realize in qualitative research both can and are used but commonly there would
be some rationale for this process given.
5) Also notice there is almost no information about the participants from the focus
group. At a minimum either match what is there for individual interviews and
include number of people in each focus group…or remove the detail for individual
interviews here.
Results:
This section reads way better than before; good work with changes and
organizing the ideas in way that brings out the importance of findings. I have 6
comments that pertain to three sections
1) Opening section: I realize there were no demographics collected from focus
group participants (wonder why?) but still encourage you to provide some details
beyond numbers of people participating. For example, were the participants
smokers or non-smokers or a mixture, for the health providers a sense of who
these folks were (type of professionals and/or years of practice-supports
credibility of data source) and for the other two groups were these woman
pregnant? Why were these women included in the focus group other than age?
2) Table 1 I have two comments…might want to indicate the ‘n’ somewhere
within the table; and I am perplexed as to how 14 out of 22 people have an
income source of pension…given their age this is counter-intuitive and might
need some statement in the text…
3)Opening section: the next paragraph sentences 2, 3, and 4 are well written and
very interesting. However, I have wondered if this is the best place for them as
they seem a bit premature being presented prior to the reader having read any of
the findings. At first my sense was to move the sentences to the opening of the
Discussion section and/or Abstract. There are similar ideas already in these two
places and so wonder about integrating or? Just not convinced they belong here
and would not want to see them simply deleted.
4) On another note of the opening to the results and the last part of the analysis. I
again questioned where best to place the sentences concerning the differences
between defined factors. While stating this analysis was done fits well within
analysis, discussion of what was found and decisions about how to present really
belongs within opening of the results section
5)Colonisation and introduction of tobacco section: the first sentence likely needs
a reference.
6) Social networks and community norms section: the second paragraph seems
unattached…I was left wondering so what? The ideas I can follow but am not
sure where they come from and why here. So wondered about integrating with
previous paragraph or including a stronger link or more of a explanation as to
why here or…
Discussion:
Here again, noticeable improvements. I really only have two comments.
1) There are several places where sentences are very very long…3 or four
lines…try to break these up as it is hard for readers to digest what you are
saying. One example is the opening sentence for this section and there are
others.
2) At the end of the second paragraph, I suggest some of the concluding ideas
go beyond what likely can be said from this study. I suggest removing the second
last sentence…as I am not convinced that you and/or a reader can draw this
concluding comparison. Also in the last sentence, I suggest making the change
to last part…’and may include a strong assertion of group identity.” Rather than
‘stronger’ again am not convinced about the comparison logically stemming from
this study
Limitations:
1) The first paragraph is not about limitations. I have wondered about moving this
to the beginning of the conclusion. However, I suggest synthesizing the ideas
into two sentences…the novelty of findings and the benefit of ongoing input from
Aboriginal peoples (am not convinced the amount of detailed repeated in this first
paragraph is necessary-this is notable in the methods and so here
acknowledging the input might be enough). As well, the sentences seem to
reflect Aboriginal people rather than Aboriginal women; I caution making these
generalizations…the purpose of this study was to focus on woman so keep the
focus there.
2) If the first paragraph is moved then, perhaps a new first sentence for the
limitation paragraph could be “Findings from this study provide novel insights into
the social context of smoking among Aboriginal woman. However, these findings
must be considered within several limitations.” Then I suggest this section needs
further development. The limitations noted include limited geographic area and
poorly educated and unemployed (these pertain to representation? And
generalizability?). Rather than rationalizing how these can be generalized
perhaps note these novel findings may be of use and that further research is
welcome to extend insights in the social context of smoking. I am not sure of the
meaning/intent of the last sentence.
Conclusion: I liked most of what is there and have simply edited the section. Here
is my suggestion for your consideration.
Through listening to the stories of Aboriginal woman and their health care
providers, findings from this study provide insights into social and cultural
influences concerning smoking initiation and maintenance. Integrating strategies
to address contextual factors will be an important next step in supporting
smoking reduction (from prevention of initiation to supporting cessation) with this
population. Recognizing the perceived benefits of smoking along with providing
alternate ways for young woman to feel included and positive about a meaningful
future are essential. Exemplars of areas noted in this study are: addressing
school transitions, improving educational opportunities and employment options.
Community involvement is necessary to shift norms and expectations regarding
smoking among Aboriginal people, with recognition that cigarette smoking is not
part of traditional Aboriginal culture. Movement forward on this health issues will
require acknowledgment of the importance of Aboriginal identity and culture as a
source of strength and empowerment, while recognizing the role of history,
dispossession and persistent marginalization in perpetuating social and financial
disadvantage contributing to high prevalence of smoking.
Abstract: I have a couple of comments regarding the abstract, which mostly
reads well
1) Third sentence under background…the sentence is a bit awkward and have
wondered how to say differently. One suggestion is to say the absence of
research focused on understanding social context surround this population likely
inhibits our effectiveness (ability) to reduce tobacco use rates.
2) In the conclusion section, please revise to focus on reducing smoking from
preventions to cessation strategies.
Level of interest: An article of importance in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.
Declaration of competing interests:
I declare that I have no competing interests