Abstract
Local coalitions can advance public health initiative but have not been widely used or well-studied in low- and middle-income countries. This paper provides (i) an overview of an ongoing matched-pairs community-randomized controlled trial in 28 communities in Armenia and Georgia (N = 14/country) testing local coalitions to promote smoke-free policies/enforcement and (ii) characteristics of the communities involved. In July–August 2018, key informants (e.g. local public health center directors) were surveyed to compare their non-communicable disease (NCD) and tobacco-related activities across countries and across condition (intervention/control). More than half of the informants (50.0–57.1%) reported their communities had programs addressing hypertension, diabetes, cancer and human papilloma virus, with 85.7% involving community education and 32.1% patient education programs. Eleven communities (39.3%) addressed tobacco control, all of which were in Georgia. Of those, all included public/community education and the majority (72.7–81.8%) provided cessation counseling/classes, school/youth prevention programs, healthcare provider training or activities addressing smoke-free environments. Informants in Georgia versus Armenia perceived greater support for tobacco control from various sectors (e.g. government, community). No differences were found by condition assignment. This paper provides a foundation for presenting subsequent analyses of this ongoing trial. These analyses indicate wide variability regarding NCD-related activities and support across communities and countries.
Introduction
Multi-sectoral local coalitions are effective policy change strategies [1–6]. Among the best-known and largest examples of such approaches is the World Health Organization’s (WHO) Healthy Cities initiative [7], an initiative that began in 1986 in high-income countries (i.e. Canada, USA, Australia, many European nations) and now involves thousands of cities worldwide. This program is successful in promoting health initiatives, community participation and empowerment and intersectoral partnerships committed to health initiatives [8, 9].
Community coalitions have been particularly well-documented as effective in shifting social norms and creating community readiness for tobacco control policies [10, 11]. The US CDC’s ‘Best Practices for Comprehensive Tobacco Control Programs’ states that ‘state and community coalitions are essential partnerships…they can keep tobacco issues before the public, combat the tobacco industry, enhance community involvement and promote community buy-in and support, educate policy makers and help to inform policy change’ (p. 18) [10]. Community Coalition Action Theory (CCAT) was developed as a framework for articulating factors influencing coalition effectiveness [12, 13] and has been highlighted as a useful model for studying community-based collaborative efforts to create policy change [14].
Unfortunately, research has found that insufficient resources can inhibit the formation and effectiveness of coalitions [15, 16]. This is particularly relevant for low- and middle-income countries (LMICs) where resources may be scarce. This is also particularly concerning given that LMICs are disproportionately affected by a range of public health problems, such as tobacco-related diseases and deaths [17, 18] including those attributed to secondhand smoke exposure (SHSe) [19]. In many LMICs, much policy progress is initiated at the national level, with data indicating that compliance with such smoke-free policies may be poor [20, 21]. Thus, parallel local work may be required shift social norms and build support for and compliance with such policies [1, 6]. Local coalitions are well-positioned to play this role.
One high-risk region for tobacco use is the area of the former Soviet Union [22]. Armenia and Georgia are two LMICs in this region that represent among the highest smoking prevalence among men (11th and 6th highest in the world; 52.3% and 57.7%, respectively), with lower smoking prevalence among women (1.5% and 5.7%, respectively) [23]. Moreover, recent data indicate high SHSe in these countries [20, 24], even in places where smoking is banned [20]. For example, a 2014 national survey indicated that 42.2% of Georgian adults reported daily SHSe, and 38.8% reported daily SHSe at home, with past-week SHSe being 54.2% in the home, 29.9% in indoor public places and 33.0% in outdoor public places [24]. In Armenia, the 2016–17 STEPS survey indicated that, among adults, past 30-day SHSe in the home was 26.6% and 56.4% at workplace [25]. These data reflect an urgent need to address the impact of SHSe in Armenia and Georgia.
The WHO Framework Convention on Tobacco Control (FCTC) mandates that nations that ratify the FCTC implement specific evidence-based tobacco control policies, including comprehensive public smoke-free legislation. Public smoke-free policies have been shown to be effective in reducing SHSe, youth tobacco use initiation, overall use prevalence and tobacco-related morbidity and mortality [26], as well as promoting cessation and reducing cigarette consumption in smokers [26].
The FCTC was ratified in 2004 and 2006 in Armenia and Georgia, respectively; however, few FCTC-recommended policies were implemented until recently. In Armenia, the current legislation, accepted in 2004, bans the consumption of tobacco in educational, cultural, healthcare, public transportation settings and in all other public buildings except dining facilities (e.g. cafes, bars, restaurants). In 2017, Armenia accepted the Tobacco Control Strategy for 2017–20 and is circulating a new draft tobacco control law, which would advance various tobacco control policies, including smoke-free air to apply to all public indoor places. In Georgia, the 2013 Tobacco Control National Strategy and 2013–18 Action Plan were adopted, and new progressive tobacco control laws were implemented in 2017–18, including a comprehensive smoke-free air policy that covers alternative tobacco products (e.g. e-cigarettes, hookah) across a broad range of indoor and outdoor areas.
In summary, given the promising effects of coalitions on advancing public health and the specific public health needs of LMICs, examining coalition effectiveness and CCAT in communities with limited resources such as LMICs is crucial in informing best practice recommendations to support local collaborative tobacco control action in such contexts [27]. Armenia and Georgia represent two LMICs with high smoking prevalence and SHSe, limited history and reach of smoke-free policies, likely policy enforcement challenges, and little history of community mobilization to promote public health initiatives [23]. Thus, the goals of the current paper are 2-fold. First, we provide a brief description of an ongoing matched-pairs community-randomized controlled trial aimed at testing the effectiveness of local coalitions in reducing SHSe in Armenia and Georgia. Second, we provide baseline characteristics of the communities selected to participate in the study, particularly in regard to their non-communicable disease (NCD) activities, and compare communities across countries and across conditions (i.e. intervention versus control) to assess and account for any baseline differences in order to inform future investigation of processes and outcomes related to this study.
Materials and methods
Ongoing study overview
This study was approved by the Institutional Review Boards of Emory University (#IRB00097093), the National Academy of Sciences of the Republic of Armenia (#IRB00004079), the American University of Armenia (#AUA-2017-013) and the National Center for Disease Control and Public Health of Georgia (#2017-026).
This study uses a matched-pairs community-randomized controlled trial and the CCAT as a framework for examining the effectiveness of local coalitions in promoting smoke-free air in Armenia and Georgia. This study defines a ‘community’ as a distinct municipality. We purposively selected 14 communities per country with (i) small to medium populations and (ii) local public health coordinating centers with sufficient capacity to engage in the proposed research. These criteria were determined for both pragmatic and scientific reasons. In particular, each country only has a couple of large cities, so working with small to medium countries was necessary to get a sufficient sample size of municipalities. Additionally, in the communities randomly assigned to be in the intervention condition, lead agencies are: (i) regional offices of Armenia’s National Center for Disease Control (NCDC) under the Ministry of Health and (ii) local municipal public health centers that collaborate with the National Center for Disease Control and Public Health (NCDC) of Georgia. Because we planned to have local public health branches/centers play key roles in coordinating local coalition activity, selected communities needed stable center leadership and sufficient resources to conduct and coordinate community-based work. Relevant to this, we attempted to match communities within each region based roughly on population size and public health branch/center budget. Scientifically, our justification for focusing on municipalities with small to medium populations is based on research that suggests that coalitions serving small to medium catchment areas are most effective in adopting evidence-based programs [1]. As indicated above, communities were paired in each country based on region (and distance from Yerevan or Tbilisi), population size and local public health branch/center budget and then randomly assigned to be in the intervention versus control conditions.
In the intervention communities, the lead agencies are charged with forming coalitions by recruiting partner organizations from civil society and other government sectors (e.g. health care, education), conducting situational assessments, and developing and implementing action plans to promote the adoption and/or enforcement of smoke-free policies. At study launch (January–February and June 2019), trainings were provided to the key members of the lead agencies, specifically to conduct situational assessments, form a coalition and execute action plans to promote smoke-free policy adoption/enforcement. Throughout the 3-year period of coalition activity, annual meetings with grantee communities will be held to present on activities, progress and lessons learned. To execute coalition activity, each intervention community receives grant funding of approximately $17 500 over the study period.
Among all 28 intervention and control communities, baseline and end-of-intervention assessments of the communities and activities in NCD prevention and control are conducted with key informants, (i.e. heads of the municipal public health centers in Georgia and regional offices in Armenia). In addition, assessments of coalition members/activities in the 14 intervention communities will be conducted throughout the study period. Among all communities (intervention and control), population-level surveys (i.e. of community member) were conducted before the launch of the coalition member trainings (October–November 2018) and then will be conducted at the end of the 3-year period (in October–November 2021).
Community capacity survey
As part of understanding the communities involved in the study, we conducted a baseline community capacity survey in July–August 2018. Heads of regional offices in Armenia and heads of municipal public health centers in Georgia were asked to complete a survey assessing their organizational characteristics, their NCD-related activities with particular questions focused on tobacco-related activities and some personal characteristics (described below).
Participant and organizational characteristics
Participants were asked to report selected sociodemographics, their role in the organization, length of employment and smoking status. They also were asked to describe the type of organization they represented (e.g. public health center; NCDC local branch) and the number of full-time staff employed by the organization.
NCD-related activities
Participants were asked: (i) whether their organization had any programs, services or activities that address various NCDs (see Table II); (ii) what programs or services they have addressing NCDs; (iii) whether any other organizations in their communities implement programs on NCD prevention and control, and if so, to describe them and (iv) whether their organization interacts with other agencies or organizations to work on NCD prevention or control, and if so, to list their partners and projects.
Table II.
Cross-country and cross-condition comparisons of organizational NCD- and tobacco-related activities
All | Armenia | Georgia | P | Control | Intervention | P | |
---|---|---|---|---|---|---|---|
NCD activities | |||||||
Have programs, services or activities that address: (N, %) | |||||||
Hypertension | 14 (50.0) | 0 (0.0) | 14 (100.0) | <0.001 | 7 (50.0) | 7 (50.0) | 0.999 |
Diabetes | 15 (53.6) | 12 (85.7) | 3 (21.4) | 0.001 | 6 (42.9) | 9 (64.3) | 0.256 |
Cancer | 16 (57.1) | 12 (85.7) | 4 (28.6) | 0.002 | 8 (57.1) | 8 (57.1) | 0.999 |
Asthma | 3 (10.7) | 0 (0.0) | 3 (21.4) | 0.067 | 1 (7.1) | 2 (14.3) | 0.541 |
Chronic respiratory disease | 6 (21.4) | 0 (0.0) | 6 (42.9) | 0.006 | 2 (14.3) | 4 (28.6) | 0.357 |
Other | 13 (46.4) | 12 (85.7) | 1 (7.1) | <0.001 | 6 (42.9) | 7 (50.0) | 0.705 |
None | 2 (7.1) | 2 (7.1) | 0 (0.0) | 0.142 | 1 (7.1) | 1 (7.1) | 0.999 |
Have programs/services provided for NCDs: (N, %) | |||||||
Primary care/clinical | 6 (21.4) | 0 (0.0) | 6 (42.9) | 0.006 | 3 (21.4) | 3 (21.4) | 0.999 |
Cancer screening | 4 (14.3) | 0 (0.0) | 4 (28.6) | 0.031 | 1 (7.1) | 3 (21.4) | 0.280 |
HPV vaccination | 14 (50.0) | 12 (85.7) | 2 (14.3) | <0.001 | 7 (50.0) | 7 (50.0) | 0.999 |
Tobacco cessation (NRT) | 5 (17.9) | 0 (0.0) | 5 (35.7) | 0.014 | 2 (14.3) | 3 (21.4) | 0.622 |
Patient education | 9 (32.1) | 0 (0.0) | 9 (64.3) | <0.001 | 4 (28.6) | 5 (35.7) | 0.686 |
Community education | 24 (85.7) | 11 (78.6) | 13 (92.9) | 0.280 | 13 (92.9) | 11 (78.6) | 0.280 |
Other | 10 (35.7) | 10 (71.4) | 0 (0.0) | <0.001 | 5 (35.7) | 5 (35.7) | 0.999 |
None | 2 (7.1) | 2 (14.3) | 0 (0.0) | 0.142 | 1 (7.1) | 1 (7.1) | 0.999 |
Other organizations in community work on NCDs (N, %) | 12 (42.9) | 8 (57.1) | 4 (28.6) | 0.127 | 5 (35.7) | 7 (50.0) | 0.445 |
Works with others on NCD prevention/control (N, %) | 20 (71.4) | 14 (100.0) | 6 (42.9) | 0.001 | 12 (85.7) | 8 (57.1) | 0.094 |
Tobacco-related activities | |||||||
Have NCD programs addressing tobacco control (N, %) | 11 (39.3) | 0 (0.0) | 11 (78.6) | <0.001 | 5 (35.7) | 6 (42.9) | 0.699 |
NCD program addresses:a | N = 11 a | N = 0 a | N = 11 a | N = 14 b | N = 14 b | ||
Cessation counseling or classes | 9 (81.8) | — | 9 (81.8) | — | 4 (28.6) | 5 (35.7) | 0.686 |
Referrals to Quitlines/cessation services | 5 (45.5) | — | 5 (45.5) | — | 2 (14.3) | 3 (21.4) | 0.622 |
School/youth prevention | 9 (81.8) | — | 9 (81.8) | — | 5 (35.7) | 4 (28.6) | 0.686 |
Healthcare provider training | 8 (72.7) | — | 8 (72.7) | — | 4 (28.6) | 4 (28.6) | 0.999 |
Public/community education | 11 (100.0) | — | 11 (100.0) | — | 5 (35.7) | 6 (42.9) | 0.705 |
Smoke-free environments | 8 (72.7) | — | 8 (72.7) | — | 5 (35.7) | 3 (21.4) | 0.064 |
Involved in influencing/developing policy on: (N, %) | |||||||
Restricting tobacco ads and displays | 12 (42.9) | 0 (0.0) | 12 (85.7) | <0.001 | 6 (42.9) | 6 (42.9) | 0.999 |
Restricting sales to youth | 13 (46.4) | 0 (0.0) | 13 (92.9) | <0.001 | 7 (50.0) | 6 (42.9) | 0.705 |
Increasing tobacco taxes | 1 (3.6) | 0 (0.0) | 1 (7.1) | 0.309 | 1 (7.1) | 0 (0.0) | 0.309 |
Increasing youth possession penalties | 1 (3.6) | 0 (0.0) | 1 (7.1) | 0.309 | 1 (7.1) | 0 (0.0) | 0.309 |
Advancing smoke-free policies | 8 (28.6) | 0 (0.0) | 8 (57.1) | 0.001 | 4 (28.6) | 4 (28.6) | 0.999 |
None of the above | 15 (53.6) | 14 (50.0) | 1 (7.1) | <0.001 | 7 (50.0) | 8 (57.1) | 0.705 |
Involved in enforcing any tobacco-related policies (N, %) | 13 (46.4) | 0 (0.0) | 13 (92.9) | <0.001 | 6 (42.9) | 7 (50.0) | 0.705 |
Perceived support for tobacco control from: (M, SD)c | |||||||
Regional government officials | 1.1 (0.6) | 0.8 (0.4) | 1.3 (0.6) | 0.030 | 1.0 (0.6) | 1.1 (0.5) | 0.510 |
Local government officials | 1.2 (0.6) | 0.9 (0.4) | 1.5 (0.7) | 0.003 | 1.1 (0.6) | 1.3 (0.6) | 0.364 |
Staff within your organization | 1.1 (1.0) | 0.1 (0.4) | 2.0 (0.0) | <0.001 | 1.1 (1.0) | 1.1 (1.0) | 0.999 |
Community members | 0.6 (0.7) | 0.1 (0.4) | 1.2 (0.6) | <0.001 | 0.6 (0.8) | 0.6 (0.7) | 0.999 |
NGOs or international organizations | 0.9 (0.9) | 0.3 (0.7) | 1.6 (0.7) | <0.001 | 0.9 (1.0) | 0.9 (1.0) | 0.861 |
Religious leaders | 0.5 (0.8) | 0.0 (0.0) | 1.2 (0.8) | <0.001 | 0.5 (0.8) | 0.5 (0.8) | 0.799 |
Among the N = 11 with NCD programs addressing tobacco control.
Calculated among the N = 14 in each condition.
On a scale of 0 = None to 2 = A lot. The number of participants indicating ‘Prefer not to answer’ were as follows: regional government officials: 1; community members: 2; non-governmental organizations or international organizations: 3 and religious leaders; 4.
Tobacco-related activities
Participants were asked: (i) whether their organization has any NCD programs that include tobacco control, and if so, to indicate the types of programs (see Table II); (ii) whether their organization is involved in influencing or developing policy or enforcement of policy in various areas; (iii) if they are involved in advancing smoke-free policies, to describe that work and (iv) whether their organization is involved in enforcing any tobacco-related policies, and if so, to describe their involvement. Participants were also asked to indicate their perceived support for tobacco control across various groups (e.g. local government, religious officials) on a scale of 0 = None to 2 = A lot, with a response option of ‘Prefer not to answer’ (see Table II).
Data analyses
Descriptive analyses were conducted, and bivariate analyses (i.e. Chi-squared for categorical variables; analysis of variance (ANOVA) tests for continuous variables) were used to compare communities across countries and communities across the intervention and control conditions. All analyses were conducted using SPSS v25.0, and alpha was set at 0.05.
Results
Participant and organizational characteristics
The majority of participants were 51–64 years old (N = 19, 67.9%), were female (N = 21, 75.0%), were employed by the organization for over five years (N = 26, 93.9%), had medical degrees (N = 18, 64.3%) and/or degrees in epidemiology (N = 17, 60.7%), and were never smokers (N = 22, 78.6%). Eleven (39.3%) respondents reported on public health centers, 14 (50.0%) were local branches of the National Center for Disease Control, with others representing municipalities, non-governmental organizations or other entities, with an average of 2.2 [standard deviation (SD) = 1.4] full-time staff (Table I). The average population of the 28 communities was 24, 114.3 (SD = 11745.7).
Table I.
Cross-country and cross-condition comparisons of participant and organizational characteristics
All | Armenia | Georgia | P | Control | Intervention | P | |
---|---|---|---|---|---|---|---|
Participant characteristics | |||||||
Age (N, %) | 0.591 | 0.501 | |||||
36–50 years | 8 (28.6) | 4 (28.6) | 4 (28.6) | 4 (28.6) | 4 (28.6) | ||
51–65 years | 19 (67.9) | 10 (71.4) | 9 (64.3) | 9 (64.3) | 10 (71.4) | ||
Older than 65 years | 1 (3.6) | 0 (0.0) | 1 (7.1) | 1 (7.1) | 0 (0.0) | ||
Sex (N, %) | 0.663 | 0.663 | |||||
Male | 7 (25.0) | 4 (28.6) | 3 (21.4) | 4 (28.6) | 3 (21.4) | ||
Female | 21 (75.0) | 10 (71.4) | 11 (78.6) | 10 (71.4) | 11 (78.6) | ||
Length of employment (N, %) | <0.001 | 0.926 | |||||
<1 year | — | — | — | — | — | ||
1–2 years | 2 (7.1) | 2 (14.3) | 0 (0.0) | 1 (7.1) | 1 (7.1) | ||
2–5 years | — | — | — | — | — | ||
5–10 years | 13 (46.4) | 12 (85.7) | 1 (7.1) | 7 (50.0) | 6 (42.9) | ||
>10 years | 13 (46.4) | 0 (0.0) | 13 (92.9) | 6 (42.9) | 7 (50.0) | ||
Educational background (N, %) | |||||||
Medical degree | 18 (64.3) | 4 (28.6) | 14 (100.0) | <0.001 | 9 (64.3) | 9 (64.3) | 0.999 |
MPH | 3 (10.7) | 0 (0.0) | 3 (21.4) | 0.067 | 1 (7.1) | 2 (14.3) | 0.541 |
Epidemiology degree | 17 (60.7) | 8 (57.1) | 9 (64.3) | 0.699 | 9 (64.3) | 8 (57.1) | 0.699 |
Other master’s degree | 1 (3.6) | 0 (0.0) | 1 (7.1) | 0.309 | 0 (0.0) | 1 (7.1) | 0.309 |
Other | 6 (21.4) | 4 (28.6) | 2 (14.3) | 0.357 | 3 (21.4) | 3 (21.4) | 0.999 |
Smoking status (N, %) | 0.654 | 0.717 | |||||
Current smoker | 3 (10.7) | 2 (14.3) | 1 (7.1) | 1 (7.1) | 2 (14.3) | ||
Former smoker | 3 (10.7) | 2 (14.3) | 1 (7.1) | 2 (14.3) | 1 (7.1) | ||
Never smoker | 22 (78.6) | 10 (71.4) | 12 (85.7) | 11 (78.6) | 11 (78.6) | ||
Organization characteristics | |||||||
Type of organization (N, %) | <0.001 | 0.543 | |||||
Public health center | 11 (39.3) | 0 (0.0) | 11 (78.6) | 6 (42.9) | 5 (35.7) | ||
National Center for Disease Control local branch | 14 (50.0) | 13 (92.9) | 1 (7.1) | 7 (50.0) | 7 (50.0) | ||
Municipality | 1 (3.6) | 0 (0.0) | 1 (7.1) | 1 (7.1) | 0 (0.0) | ||
Non-governmental organization | 1 (3.6) | 0 (0.0) | 1 (7.1) | 0 (0.0) | 1 (7.1) | ||
Other | 1 (3.6) | 1 (7.1) | 0 (0.0) | 0 (0.0) | 1 (7.1) | ||
Full-time staff (M, SD) | 2.2 (1.4) | 2.7 (1.4) | 2.0 (1.3) | 0.323 | 2.3 (1.4) | 2.1 (1.3) | 0.730 |
Community population (M, SD) | 24114.3 (11735.7) | 19835.7 (10873.7) | 28392.9 (11330.5) | 0.052 | 24971.4 (12768.7) | 23257.1 (11019.2) | 0.707 |
NCD-related activities
Half or more of the communities had programs, services or activities addressing hypertension (50.0%), diabetes (53.6%) or cancer (57.1%; Table II). Georgian communities were more likely to have NCD programs addressing hypertension (P < 0.001) and chronic respiratory diseases (P = 0.006), while those in Armenia were more likely to have NCD programs addressing diabetes (P = 0.001), cancer (P = 0.002) and other programs (e.g. diet, alcohol use, P < 0.001).
The vast majority (85.7%) had NCD programs involving community education, with 50.0% having human papillomavirus (HPV) vaccination promotion programs and 32.1% having patient education programs. Georgian communities were more likely to have NCD programs that provided primary care or clinical services (P = 0.006), cancer screening (P = 0.031), tobacco cessation (P = 0.014) and patient education (P < 0.001). Armenian communities were more likely to have NCD programs providing HPV vaccination (P < 0.001) and other services (e.g. NCD epidemiological surveillance, prevention related to risk factors, population awareness programs, P < 0.001).
Almost half (42.9%) of the communities had other organizations in their communities working on NCD prevention and control. Of the eight Armenian communities indicating such organizations, these largely represented local non-governmental organizations (NGOs) and international organizations working on health care, youth, children and women’s issues (e.g. ‘Young Families Support Center’ NGO, ‘Young Generation’ NGO, World Vision’s regional branches and Red Cross regional offices). Of the four Georgian communities indicating such organizations, these included other public healthcare centers and involved activities around cancer screenings.
Three quarters (71.4%) worked with other groups on NCD prevention and control. Armenian organizations were more likely than those in Georgia to work with other organizations/partners on NCD prevention and control (P = 0.001). In Armenia, two collaborations universally reported included: (i) regional administration and the mayor’s office on NCD risk factors and (ii) medical facilities on epidemiological surveillance of chemical poisoning and injuries. In Georgia, these collaborations varied and included working with: (i) the NCDC on a campaign to increase blood pressure screening and reduce the impact of hypertension and (ii) local governmental and educational institutions (pre-schools and schools) for Enterobiasis and iodine deficiency screening.
Tobacco-related activities
Eleven communities (39.3%) addressed tobacco control, all of which were located in Georgia (Table II). Of those, all included public/community education, and nearly all provided cessation counseling or classes (81.8%), school/youth prevention programs (81.8%), healthcare provider training (72.7%) or activities addressing smoke-free environments (72.7%).
Of the 28 communities, 53.6% reported no involvement in any of the tobacco control policy efforts assessed; however, 46.4% were involved in influencing, developing, or enforcing policy on restricting sales to youth, 42.9% in restricting tobacco ads and displays and 28.6% in smoke-free policies. Thirteen (46.4%) of the communities reported being involved in enforcing any tobacco-related policy. Those communities involved in these activities were all located in Georgia. These activities included a broad range of initiatives related to the implementation and monitoring of the tobacco control policies implemented in 2018, specifically: educating the local community and small businesses regarding the tobacco control legislation that went into effect in May 2018 via public meetings; informative-consulting visits with stakeholders and target institutions; tobacco product retail monitoring; educational meetings with youth and prospective mothers on tobacco-relate harms; and monitoring the enforcement of and compliance with the smoke-free policy in various locations (e.g. retail stores, restaurants, public transportation, and public, administrative and educational facilities).
Average scores regarding perceived support for tobacco control were highest regarding support from local government officials and lowest from religious leaders and community members. The key informants in Georgia versus Armenia rated the support they perceived from the various groups as greater (P’s < 0.05, respectively).
Discussion
This paper provided baseline data comparing communities involved in an ongoing trial examining coalition processes and activities, particularly in relation to organizational activities and existing capacity to mobilize their communities toward social norms and policy change around tobacco and NCDs more broadly. No differences were documented between the intervention and control communities, a critical finding that establishes that the randomization was effective in establishing conditions with similar baseline characteristics deemed important for this trial. Moreover, these communities reported considerable local activity across a range of NCD-related public health issues, particularly cardiovascular disease, cancer, diabetes and HPV prevention, with the most prominent programs involving community and patient education. Also of note is that almost half had other organizations in their communities working on NCD prevention and control, and nearly three quarters worked with other groups on NCD prevention and control. Regardless of some differences across countries, findings from the current study indicate promising existing capacity to promote NCD-related activities across communities, which CCAT suggests may facilitate effectiveness [12, 13].
While no differences were found across conditions, some pronounced differences were found across the two countries, particularly regarding tobacco control activity. This is likely due to the more aggressive timeline and recent action related to tobacco control in Georgia, with its implementation of several progressive tobacco control measures in 2017–18. In addition, in 2018, Georgia was one of the 15 FCTC parties (and the only European country) selected to receive direct support under the FCTC 2030 project. In brief, FCTC 2030 started in February 23018 and involved technical and logistical support the new tobacco legislation, communication strategy development and implementation, fostering mobilization of stakeholders and dialog among them, and awareness raising about upcoming legislative changes among civil society, state structures, retailers, the hospitality industry, etc., among other supports and activities. This additional support in Georgia facilitated local public health agencies’ work related to the implementation of various tobacco control measures, including those related to the implementation of the smoke-free air policy.
While this opportunity has supported and catalyzed tobacco control efforts in Georgia, it has created differences in tobacco control activity between the two countries. Moreover, additional measures in Georgia regarding tobacco control more generally (e.g. plain cigarette packaging) and smoke-free air specifically (e.g. tobacco-free stadiums and hotels) are on the horizon. However, it is also critical to note pending legislative actions in Armenia to advance tobacco control legislation (e.g. pictorial health warnings) including smoke-free air policies (i.e. a comprehensive public policy).
Indeed, community-based research often faces challenges in terms of unexpected events that might occur and ‘noise’ that impacts the research design and interpretation of findings [28, 29]. Specific to the current study, irrespective of the coalition intervention being tested in this trial, these policy changes and external support for tobacco control will likely impact local community capacity, community mobilization, social norms related to tobacco and SHSe. Another concern that is more difficult to address is the possibility of a ceiling effect that might hinder interpretation of study results. More specifically, these external change agents could result in drastic reductions in SHSe, thus limiting the extent to which we will be able to detect differences in changes in SHSe from baseline to follow-up between the intervention and control conditions, particularly given the modest power of involving 28 communities and roughly 1500 community survey participants at each time point.
From this perspective, there are several ways in which the research design will yield important findings regardless. First, the nature of the randomized control trial is critical, as it allows isolation of the effects of the intervention. Second, examining baseline capacities allows us to account for the differences in community capacity across countries in subsequent analyses. Third, we will use CCAT as a framework for studying coalition processes and the types of advantages such external changes or support related to tobacco control might entail. Examining coalition processes within this context during dynamic changes will call for thoughtful ways in which to leverage this opportunity by integrating these evolving factors into study measures and contextualization of the results. Indeed, this multifaceted research design will yield findings that will contribute to the literature and inform CCAT [12] and future public health practice.
Conclusions
In conclusion, multi-sectoral local coalitions aligning civil society and local public health agencies is a well-documented strategy for effecting policy change [1–6]. It is critical to understanding coalition characteristics and processes, as well as sociocontextual factors (e.g. political context), that foster success in local coalitions in communities with limited resources such as LMICs [27]. This paper serves as a foundation to provide context for subsequent analyses related to an ongoing, long-term community-randomized control trial testing the impact of local coalitions in LMICs to effect policy change and enforcement, specifically focused on smoke-free air. This initial set of analyses indicated that the randomization of the 28 cities yielded no differences in important community and organizational factors relevant to the implementation of the trial. It also highlights the types of NCD- and tobacco-related activities taking place in Armenia and Georgia, which might provide some indication of such activities in the region more broadly. Ultimately, the parent study will serve as a catalyst for future research and evidence-based practice to support tobacco control progress in LMICs and more broadly.
Acknowledgements
We would like to thank our community partners for their participation in the ongoing study and its execution.
Funding
This work was supported by the US Fogarty International Center/National Cancer Institute (1R01TW010664-01; MPIs: Berg, Kegler). Dr. Berg is also supported by the National Cancer Institute (R01 CA215155-01A1; PI: Berg; R01 CA179422-01; PI: Berg; P30 CA138292; PI: Curran).
Conflict of interest statement
None declared.
References
- 1. Spicer N, Harmer A, Aleshkina J. et al. Circus monkeys or change agents? Civil society advocacy for HIV/AIDS in adverse policy environments. Soc Sci Med 2011; 73: 1748–55. [DOI] [PubMed] [Google Scholar]
- 2.Center for Civil Society. London School of Economics and Political Science. Available at: http://www.lse.ac.uk/collections/CCS/what_is_civil_society.htm. Accessed: 13 August 2019.
- 3.American Cancer Society. Guide 2. Strategy Planning for Tobacco Control Movement Building. Available at: http://www.strategyguides.globalink.org/. Accessed: 13 August 2019.
- 4.American Cancer Society. Guide 3. Enacting Strong Smoke-Free Laws: The Advocate’s Guide to Legislative Strategies. Available at: http://www.cancer.org/downloads/AA/Legislative_Strategies.pdf. Accessed: 13 August 2019.
- 5.World Health Organization. Stop the Global Epidemic of Chronic Disease: A Practical Guide to Successful Advocacy. Geneva: WHO, 2006. Available at: http://www.who.int/chp/advocacy/en/. Accessed: 13 August 2019. [Google Scholar]
- 6. Champagne BM, Sebrie E, Schoj V.. The role of organized civil society in tobacco control in Latin America and the Caribbean. Salud Publica Mex 2010; 52: S330–9. [DOI] [PubMed] [Google Scholar]
- 7. Tsouros AD. The Who Healthy Cities Project: state of the art and future plans. Health Promot Int 1995; 10: 133–41. [Google Scholar]
- 8. Boonekamp GMM, Colomer C, Tomas A. et al. Healthy Cities Evaluation: the co-ordinators perspective. Health Promot Int 1999; 14: 103–10. [Google Scholar]
- 9. Kenzer M. Healthy Cities: a guide to the literature. Public Health Rep 2000; 115: 279–89. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs. Atlanta: U.S. Department of Health and Human Services, 2014. [Google Scholar]
- 11. Stillman FA, Hartman AM, Graubard BI. et al. Evaluation of the American Stop Smoking Intervention Study (ASSIST): a report of outcomes. J Natl Cancer Inst 2003; 95: 1681–91. [DOI] [PubMed] [Google Scholar]
- 12. Butterfoss F, Kegler MC.. The community coalition action theory In: DiClemente R, Crosby L, Kegler MC (eds). Emerging Theories in Health Promotion Practices and Research, 2nd edn. San Francisco: Jossey-Bass, 2009, 237–76. [Google Scholar]
- 13. Butterfoss FD, Kegler MC.. Toward a comprehensive understanding of community coalitions: moving from practice to theory In: DiClemente R, Crosby L, Kegler MC (eds). Emerging Theories in Health Promotion Practices and Research. San Francisco: Jossey-Bass Publishers, 2002, 414. [Google Scholar]
- 14. Flood J, Minkler M, Hennessey LS. et al. The Collective Impact Model and its potential for health promotion: overview and case study of a healthy retail initiative in San Francisco. Health Educ Behav 2015; 42: 654–68. [DOI] [PubMed] [Google Scholar]
- 15. Harpham T, Burton S, Blue I.. Healthy city projects in developing countries: the first evaluation. Health Promot Int 2001; 16: 111–25. [DOI] [PubMed] [Google Scholar]
- 16. Khoshchashm K. Rapid Urbanization and Healthy Cities and Healthy Villages Programs in the Eastern Mediterranean. Transforming Distressed Global Communities: Making Inclusive, Safe, Resilient, and Sustainable Cities 2015; 277–302. [Google Scholar]
- 17.World Health Organization. WHO Report on the Global Tobacco Epidemic. Geneva, Switzerland: World Health Organization, 2011. [Google Scholar]
- 18. Lopez AD, Mathers CD, Ezzati M. et al. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2006; 367: 1747–57. [DOI] [PubMed] [Google Scholar]
- 19. Oberg M, Jaakkola MS, Woodward A. et al. Worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries. Lancet 2011; 377: 139–46. [DOI] [PubMed] [Google Scholar]
- 20. Movsisyan N, Petrosyan D, Petrosyan V.. monitoring compliance with smoke-free legislation to advance the FCTC implementation in Armenia. In 15th World Conference on Tobacco or Health, Singapore, 2012. [Google Scholar]
- 21. Movsisyan N, Petrosyan V.. Analytical Review of the Tobacco Control Policy in Armenia 2005-2007 . Yerevan, Armenia: Center for Health Services Research and Development, 2008. [Google Scholar]
- 22. Roberts B, Gilmore A, Stickley A. et al. Changes in smoking prevalence in 8 countries of the former Soviet Union between 2001 and 2010. Am J Public Health 2012; 102: 1320–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.World Health Organization. Prevalence of Tobacco Smoking 2015. Available at: http://gamapserver.who.int/gho/interactive_charts/tobacco/use/atlas.html. Accessed: 13 August 2019.
- 24. Berg CJ, Topuridze M, Maglakelidze N. et al. Reactions to smoke-free public policies and smoke-free home policies in the Republic of Georgia: results from a 2014 national survey. Int J Public Health 2016; 61: 409–16. [DOI] [PubMed] [Google Scholar]
- 25.World Health Organization. ARMENIA STEPS Survey 2016-2017: Fact Sheet, 2017. Available at: https://www.who.int/ncds/surveillance/steps/Armenia_2016_STEPS_FS.pdf. Accessed: 13 August 2019.
- 26.Centers for Disease Control and Prevention. The Guide to Community Preventive Services, 2012. Available at: http://www.thecommunityguide.org/index.html. Accessed: 13 August 2019.
- 27. Berg CJ. Local coalitions as an underutilized and understudied approach for promoting tobacco control in low- and middle-income countries. J Glob Health 2019; 9: 010301. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28. Hohmann A, Shear M.. Community-based intervention research: coping with the “noise” of real life in study design. Am J Psychiatry 2002; 159: 201–7. [DOI] [PubMed] [Google Scholar]
- 29. Berg CJ, Thrasher JF, Barnoya J. et al. Strengthening policy-relevant tobacco research capacity in low- and middle-income countries: challenges, opportunities and lessons learned. Nicotine Tob Res 2019; 21: 1140–3 [DOI] [PMC free article] [PubMed] [Google Scholar]