The ITC South East Asia Project

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• The ITC South East Asia Project
• Ron Borland PhD
• The Cancer Council Victoria
• Principal Investigator for the
• ITC SEA Team

Measuring the Effectiveness of Tobacco Control
WorkshopBethesda, Maryland, USAJuly 2006
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ITC-SEA Investigators (include)

• Ron Borland
• Geoffrey T. Fong
• Buppha Sirirasamee
• Maizurah Omar
• Gary A. Giovino
• David Hammond
• Hua Yong
• Hana Ross

• Foong Kin
• Rahmat Awang
• Chanya Sethaput
• Stephen Hamann
• Aree Prohmmo
• Phillip Guest

Mainly funded by NIH via Roswell Park TTURC
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The ITC SE Asia Project

• Background to the ITC SEA Project
• Why have it?
• What are some of the challenges we face?

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The ITC SEA Project Why have it?

• Do policies that work in affluent
  English-speaking countries work in SE Asia?
• Are there differences in the way that policies
  operate or in their relative efficacy?
• What characteristics of smokers are responsible
  for any differences in policy effects between
  affluent English-speaking countries and in SE
  Asia?
• SEA countries(esp Thailand) are policy leaders,
  so evaluation especially important in SEA

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ITC SEA Research Questions (some)

• Describe smokers in these countries
• Effects of graphic health warnings in Thailand
• Effects of ban on displays at point of sale
• Explore role of religion
• Explore role of collectivism
• Are effects the same as in ITC-4 country?
• If not , what makes the difference?

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What are the big differences between Malaysia,
Thailand versus USA, Canada, UK, and Australia?

• Tropical versus temperate climate
• Languages
• Middle income versus high income
• Religion
• Centrality of religion in SE Asia
• Collectivist vs. individualist orientation
• Gender differences
• few women smoke in Asia

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Why Thailand and Malaysia?

• Thailand leader in tobacco control with strong
  programs for some time
• Malaysia recently has started taking serious
  action
• Potential for interesting comparisons
• Both have the research capacity within the
  country to conduct the ITC survey

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Choice of survey method

• ITC 4 Country CATI
• ITC SEA face to face
• Low telephone penetration, especially rural
• Novelty of phone surveying
• Face to face relatively cheaper than in rich
  countries
• Level of adult literary too low for
  self-completion
• Self-completion used for adolescents
• Facilitates privacy of responding

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Pros and Cons of face to face surveys

• Pros
• Whole of household approach
• Male smoker
• Female smoker
• Adolescent
• Adult non-smoker
• Capacity to show pictures (for recognition
  measures of ongoing mass media campaign)
• Cons
• Sampling design and pre-survey work more
  complicated and demanding
• 3 levels of clustering used in SEA surveys

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Sampling frame

• Urban vs Rural locations
• Urban less expensive because of lowered costs of
  staff travel
• Rural higher response rates
• Rural shorter time window for surveying
• Differences in culture and sophistication
• Higher Illiteracy in rural settings
• Different product use (eg roll-your-own) in rural
  settings

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ITC SE Asia Surveys

• 2000 adult smokers in each country
• Males and females recruited separately
• Can be one of each from same household
• 1000 youth (13-17) in each country
• From smoker and non-smoker households
• 1500 adult non-smokers (Malaysia only)

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ITC SE Asia Surveys Survey Content

• Began with ITC Four Country Survey
• Assessed survey items for relevance in SE Asia
• Eg Fewer items on Light and Mild issue
• Assessed each survey item for comprehension in
  Thailand and in Malaysia
• Created items to measure content domains of
  special importance in Thailand and/or Malaysia
• Eg Role of religion
• Feedback to other surveys

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Translation

• Translation and back translation critical
• Dealing with ambiguities and extended reference
  of terms
• Seek conceptual equivalence not literal
  equivalence
• Translation of jargon, metaphor etc
• Must use language the target population
  understands

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Composition of the ITC SEA Research Team

• Western scientists
• A team of specialists
• Little local knowledge
• Local scientists
• Some of the few tobacco control researchers in
  the country
• Some may be new to tobacco control
• Generalists

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Working with a multi-cultural team across
countries

• Need for occasional face-to-face meetings
• Sensitive to cultural differences in interaction
• Sensitive to cultural differences in thinking
  about research
• Priority and type of publications
• Reports for government and selected others
• Manuscripts for peer-reviewed literature

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ITC SEA Preliminary findings

• Thai smokers see smoking as less socially
  accepted and much stronger negative attitudes to
  smoking than Malaysians
• Thai efforts to eliminate promotion of tobacco
  products have been largely successful
• Thai warning labels (old ones) were more
  effective than the weaker Malaysian ones
• The Thai graphic warnings are likely to be even
  more so
• Thai smokers are not systematically more likely
  than Malaysian smokers to support smoke free
  places

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ITC SEA The future

• Funded for 4 waves of surveying
• Funding delays made gap between first and second
  waves longer than others will be
• Need to replenish cohort at each wave
• Replenishment due to cohort members lost to
  attrition
• Greater need for replenishment in urban sampling
  areas (because of higher attrition rates)

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Conclusions

• Culture matters when surveying
• Must be sensitive to cultural differences and
  expectations
• Face-to-face surveying increases challenges
• Translation is more than simple literal word by
  word substitution
• Working with different cultures is a challenge
• But it brings huge rewards

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International Tobacco Control Policy Evaluation
Projecthttp / / www.itcproject.org http / /
www.roswelltturc.org
 
ITC Project Research Support
Core support provided by the U.S. National Cancer
Institute to the Roswell Park TTURC (P50 CA111236)
Additional major funding provided by the Canadian
Institutes of Health Research