Reviewer's report
Title:"Its almost expected": influences on smoking initiation and maintenance
among Aboriginal women in rural Australia: a qualitative study
Version: 1Date:26 April 2011
Reviewer: Annette Schultz
Reviewer's report:
Reviewer: Annette Schultz, PhD, RN
Report for BMC Women’s Health manuscript titled:
“Its almost expected”: influences on smoking initiation and maintenance among
Aboriginal women in rural Australia: a qualitative study
Dear Dr. Passey,
Great to see research work focused on tobacco use issues situated within an
Aboriginal world view. As you know this is rare and perplexing given the high
rates of tobacco use among Aboriginal peoples. The following review report
begins with addressing the BMC questions, which is followed by an additional
comments section. On a final note, while I appreciate the research topic area and
study, the manuscript requires considerable revisions.
When assessing the work, please consider the following points:
1. Is the question posed by the authors well defined?
There are four places that the purpose of the study is alluded to and all are not
congruent. The last sentence/paragraph of the “Background” section is the first;
next is the first sentence of the “Methods” section; then the last sentence of this
paragraph, which makes the clearest purpose statement; and finally the two
objectives noted on the top of page 6. The outcome of these is a lack of clarity
about the purpose what is presented in this manuscript and how that is situated
within a larger project. I suggest a clear and simple statement at the end of the
“Background” section. Then in the methods there can be mention that the
findings reported on here are part of a larger study that focused on XX. On a final
note, the specific objectives read more like focus group and/or interview
questions that guided discussions with Aboriginal women and Health workers (as
I worked through the review report, I realized that indeed these objectives appear
again under data collection…my suggestion only have them appear once under
the data collection section).
2. Are the methods appropriate and well described?
I suggest the study site details be moved to the Methods section. Regarding
content, I wondered if there was any specific tobacco control policy and/or
programs in this community that could be shaping these women’s perceptions. If
there was, the policy/program could inform interpretation of data. This notion fits
in well with contextual factors.
I suggest opening the Methods section with a statement like
This qualitative study involved Australian Aboriginal women from a rural
community in focus groups and semi-structured interviews to explore their
perceptions of (specific objectives). The findings presented here are part of a
larger project focused on XX. A theoretical premise underlying this project was
SCT, which suggests this XX. The perspective shaped our decisions to XX
(While I appreciate the one sentence about SCT…am not convinced this is
adequate…how did this shape the study, research questions and/or
analysis…why did you use this theory?) Ethical approval for this study was
obtained from XX.
I like the paragraph about the CRG, here I began to wonder about the influence
of Action Research?
Why has this study included both Aboriginal women and Aboriginal health care
workers? Would be useful what was underlying this decisions rather than
focusing only on Aboriginal women.
Data collection: here I began to wonder if the study has a focus on pregnant
Aboriginal women and smoking/tobacco use (this is a tricky point as sometimes
in the manuscript is appears simply Aboriginal woman and smoking and others
specific to pregnancy)…I suggest this shifting focus could be clarified and the
manuscript be consistent. Perhaps the focus is women and a reason this is
important is because of the concerns/health risks during pregnancy and their role
with children. Again go back and visit purpose statement in the background.
Why were there follow up interviews? Was there something about the focus
groups or was this always the plan…if so, what was the rationale?
Topic areas discussed; the content was previously identified objectives that I
suggested were guiding discussion questions for the focus group and interview
discussions. I suggest a better fit here and there is no need to repeat them.
Data analysis and management is mostly well done! I appreciate the inclusion of
the CRG role in analysis.
I suggest a statement about themes (codes) presented here (that is based on the
last sentence) belongs in the opening for the Results section
Ethical approval sentence could be situated at the end of the opening sentence
for the methods section. Also…please note: it is not my preference to ever have
a paragraph with one or even two sentences. Commonly the point in the
sentence either needs fleshing out or really belongs linked to some other point.
3. Are the data sound?
Why are there no demographic details for the focus group participants?
The statement about content from the focus groups and interviews (one sentence
after Table 1 here) does not belong under results. Rather this information is
relevant to Methods section.
Feedback on the Themes presented:
Each theme would benefit from the addition of an opening sentence that defines
what the theme reflection; sort of, a definition. Otherwise the reader is left
wondering how these presented details relate to the theme title along with how
themes are related and/or different. For example some of content under culture
(within Contextual factors section) I think overlaps with content in other areas
within this section. Thus, when I read the last one, cultural, I was left wondering
how the ideas are different and unique from the others.
Contextual factors…
The Historical factors, seems a bit superficial and I wanted a bit more about what
all was being implied; of course not sure it is possible based on data. Social
networks and community norms theme is a bit unfocused and it took me several
reads to get clear. It appears this section focuses mostly on the influence of
marginalization, which leads to limited interaction outside of the community,
difficultly in making changes and strength of social bonds in a community with
high rates of smoking, along with Aboriginal identity. This section need to be
simplified and focused…I get lost and begin to wonder about its intent. Even
reviewing these key areas, I am left wondering what about the common thread.
The section on disadvantaged and stressful lives is more clearly focused.
Comments about the cultural theme are noted above in my initial example.
Initiating smoking
Again, I found the ideas presented within the four areas overlapped. What this
suggests to me, is additional interpretation is required to clarify the content of the
identifying area, what is implied and what are the best examples.
Opening about initiation age…is this only of the 22 women? There is no
indication of who is being represented here. Needs clarifying…
The sentence…Within the context of separate social networks with a high
prevalence of smoke, the following four core themes emerged in relation to
smoking initiation…I am unclear as to what this means? What separate social
networks are being referred to?
Peer influences and needing to belong, smoking as status
The section is mostly well written but the title is unclear and not a great descriptor
of the section; this areas seems to focus on reasons why people begin smoking
and a few factors that created a temporary buffer
Cultural factors, parenting and social structures
Here the topics are about the social fabric within the community, how this shapes
unique parenting situations, effects women’s ability to influence children, and
opens opportunities to obtain cigarettes (seems like peer influences?) Note:
throughout the manuscript I wondered what culture means within the context of
this paper and wondered about having a brief definition in the opening…see
below under earlier paragraphs in the discussion section
Development of identity would benefit from a clear opening explanation of what it
means within the context of this manuscript. A key topic here is the lack of other
factors to shape their identity and so smoking becomes part of it when within a
community with high rates of smoking
Not smoking section…provides the alternate position.
4. Does the manuscript adhere to the relevant standards for reporting and data
deposition?
I suggest the results section could be stronger and clearer in the presentation of
findings. Strategies to achieve this are simplifying titles, opening each with a
clear statement about what it means for the purpose of this manuscript and then
follow this description with examples and why they are important. This section
demonstrates interesting ideas from the study but a weak presentation of them.
5. Are the discussion and conclusions well balanced and adequately supported
by the data?
Discussion:
The opening paragraph provides additional insight into how the areas addressed
in the results are linked. I actually wonder if this information earlier would
strengthen the results section by allowing the reader to have a framework for
what is presented. Perhaps reworked as an opening for the results section?
The next paragraph begins with a sentence that is 5 lines long…way too long.
The ideas here about history of tobacco use and the importance of context
belong in the background section. This paragraph would assist the reader in
knowing the importance of the two main areas discussed with participants. Also
as noted earlier, would be useful to have a definition of culture in the background
section.
New information about the setting is presented in the next two paragraphs.
These details are important to understand the data; thus, this is not where these
ideas belong. Rather their relevancy would be more potent prior to the results
section.
I am a bit lost with the discussion, it is not well organized and therefore, have
minimal to say about each paragraph. Here is my sense of important key ideas
that could be discussed…one paragraph for each (some of which has been
done)
1. Family structures and obligations to relations
2. Separate social networks roles in smoking behavior among Aboriginal
Australians; although not entirely sure I know what it means yet..
3. Ideas of initiation influences
4. Paragraph about collective social practice
Conclusion:
This is written well and the progression of ideas is easy to follow. Just wish the
manuscript provided a more solid foundation of ideas to support what I think is
likely a logical conclusion.
6. Are limitations of the work clearly stated?
Strengths are well highlighted and the paragraph is a bit choppy; could use an
edit.
The next two paragraphs concerning limitations are problematic. While the
influencing mechanisms of factors and generalisability are important apects to
address for quantitative approaches, they are not necessarily useful for
qualitative studies. Commonly qualitative studies aim to shed new light on a
topic, providing novel evidence to critically reflect on and/or question held
assumptions, and provide guidance for future work. Limitations here could
include small number of non-smokers…but otherwise the weaknesses are not
really for qualitative work. See argument for this in Schultz, ASH., Bottorff, JL.,
Johnson, JL. (2006). Tobacco within acute care hospitals: An ethnographic study
of nurses' workplace. Tobacco Control; 15(4):317-22.
7. Do the authors clearly acknowledge any work upon which they are building,
both published and unpublished?
Not sure I can comment on this regarding the authors work. See below, under
additional comments, for my perception of situating this study within relevant
published literature.
8. Do the title and abstract accurately convey what has been found?
The title is awkward, here is my suggested revision
“Its almost expected” rural Australian Aboriginal women’s reflections on smoking
initiation and maintenance: a qualitative study
Abstract: no comment on the abstract at this time. The manuscript requires
significant revisions, which might alter the abstract content as well.
9. Is the writing acceptable?
The manuscript is not well written. There are organizational issues, as noted
above, which effects flow and building of the ideas. In addition, there are many
very long sentences, which commonly suggest too many ideas being address in
one sentence. Better to break these up and flesh them out a bit. Also, as noted
previously, paragraphs commonly contain ideas addressed through several
sentences and not only one or two.
Additional comments:
The manuscript is not well situated within relevant literature. Although I agree
there is a dearth of literature focused on the specific topic, there has been work
published that could be relevant.
Here are two Canadian authors to consider and I include an example of
published article for each. While the titles are not an absolute match for your
topic area, I suspect from the titles there will be relevant material in each. Also
each of these authors may have other articles of importance and/or the reference
list from these two articles might prove fruitful for other published work of
importance to this study.
Bottorff, Joan…A family affair: Aboriginal women’s efforts to limit second-hand
smoke exposure at home
Greaves, Lorraine…Where there is smoke, there is stress: Low-income women
identify support needs and preferences for smoking reduction.
In addition, Greaves published a book (from her dissertation work) about women
and smoking called Smokescreen. I believe there are findings from this study that
are relevant to your findings and why it is essential that we hear the voices of
Aboriginal women concerning tobacco use issues and the situatedness within
their everyday lives.
Given this concern regarding relevant literature, I found the background weak
and not well organized. The points raised are of interest but how they are
presented is unconvincing and there is at least one additional topic of importance
(historical context).
To begin with I would not open with a statement about rates; rather, open with a
statement about why addressing tobacco is important among woman and in
particular Aboriginal woman. Then state actual rates, which can then be followed
by a statement about the amazing dearth of evidence available to inform policies
and programs focused on addressing tobacco miss-use within these
communities.
Then yes to the topics in the next two paragraphs but see if there is additional
literature. Then I would also include a paragraph about context, culture, and
history.
On a final note, decided to draw on references lists from some of my graduate
students working on related research topic areas. While I provide this list of
potentially relevant articles, know that these are simply suggestions and that my
inclusion was based on title...
Blondin, B. (1990). Traditional use of tobacco among the Dene. Arct Med Red,
49(S2), 51-53.
Burgess, D., Fu, S.S., Joseph, A.M., Hatsukami, D.K., Solomon, J., & van Ryn,
M. (2007). Beliefs and experiences regarding smoking cessation among
American Indians. Nicotine and Tobacco Research, 9(1), S19-S28.
Gryczynski, J., Feldman, R., Carter-Pokras, O., Kanamori, M., Chen, L., & Roth,
S. (2010). Contexts of tobacco use and perspectives on smoking cessation
among a sample of urban American Indians. Journal of Health Care for the Poor
and Underserved, 21(2), 544-558.
Hill, D.L. (2006). Sense of belonging as connectedness, American Indian
worldview, and mental health. Archives of Psychiatric Nursing, 20(5), 210-216.
Ivers, R.G. (2004). An evidence-based approach to planning tobacco
interventions for Aboriginal people. Drug and Alcohol Review, 23, 5-9.
LeMaster, P.L, Connell, C.M., Mitchell, C.M., & Manson, S.M. (2002). Tobacco
use among American Indian adolescents: protective and risk factors. Journal of
Adolescent Health, 30(6), 426-432.
Makosky-Daley, C., James, A.S., Barnoskie, R.S., Segraves, M., Schupbach, M.,
Schupbach, R., & Choi, W.S. (2006). Tobacco has a purpose, not just a past:
feasibility of developing a culturally appropriate smoking cessation program for a
pan-tribal native population. Medical Anthropology Quarterly, 20(4), 421-440.
Stuthers, R., Eschiti, V. S., & Patchell, B. (2004). Traditional indigenous healing:
Part 1. Complementary Therapies in Nursing & Midwifery, 10, 141-149.
Walters, K.L., Simoni, J.M., & Evans-Campbell, T. (2002). Substance use among
American Indians and Alaska Natives: Incorporating culture in an “indigenist”
stress-coping paradigm. Public Health Reports, 117(1), S104-S117.
Weaver, H., & BraveHeart, M. (1999). Examining two facets of American Indian
identity: Exposure to other cultures and the influence of historical trauma. Journal
of Human Behavior in the Social Environment, 2(1/2), 19-33).
Whitbeck, L.B., Chen, X., Hoyt, D.R., & Adams, G.W. (2004). Discrimination,
historical loss and enculturation: culturally specific risk and resiliency factors of
alcohol abuse among American Indians. Journal of Studies on Alcohol, 65(4),
409-418.
Winter, J. (2006). Sacred smoke, silent killer: spiritual use or tobacco abuse?
CrossCurrents: The Journal of Addiction and Mental Health, 10(1), 9.
Level of interest: An article of outstanding merit and interest in its field
Quality of written English: Needs some language corrections before being
published
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