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GATS Turkey Implementation and Challenges

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                                  GATS Turkey: Implementation and Challenges

               Enver Tasti
               Turkish Statistical Institute (TurkStat). Head of Social Statistics Department,
               Necatibey Cad. No: 114, Anittepe, 06100 Ankara, Turkey.
               E-mail: Enver.tasti@tuik.gov.tr
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               1. Introduction
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               The Global Adult Tobacco Survey (GATS) in Turkey is a nationally representative household survey of
               adults age 15 and older with an objective to assist Turkey in the formulation, tracking and implementation of
               effective tobacco control interventions and provide an opportunity to compare the tobacco use estimates
               within and across countries implementing GATS. The GATS in Turkey was initiated in October 2007 and is
               being implemented by the Turkish Statistical Institute (TurkStat) after a formal agreement was co-signed by
               Ministry of Health (MoH) and GATS Partners.
               After introductory meetings, TurkStat adopted the GATS questionnaire in April 2008. In these meetings,
               specific details on questionnaire and sampling designs associated with the GATS were also discussed.



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               2. GATS in Turkey
               Prior to the main field study, a two-step pilot testing was planned. At the first step, the “pretest” aimed to
               use paper-pencil version of the GATS questionnaire only, to check for the understandability of the questions,
               translation problems (if any), the appropriateness of the flow of the questions and properness of the skip
               patterns on a number of individuals residing in rural and urban settings.
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               The pretest was conducted on a convenience sample of 121 individuals residing in Ankara and despite its
               non-representative nature, interviewers aimed to reach adequate number of females and males in both rural
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               and urban settings, given that socioeconomic and cultural characteristics of participants would affect the
               responses. A total of 20 interviewers working as TurkStat staff in Ankara took part in the survey.
               Preceding the field study, interviewers had training in TurkStat central office on the objectives of the study,
               the GATS questionnaire and how to implement the survey.


               Following the pretest field study, an evaluation meeting was realized in TurkStat and each interviewer
               explained the problems faced in the field, detailed the issues regarding the understandability of the questions
               and suggested his/her alternative question styles.



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               At the second step, the “pilot study,” TurkStat conducted household surveys through 26 regional offices
               located in 26 different cities scattered around Turkey and those are responsible to collect data from all
               provinces (81) in Turkey. These regional offices were responsible for gathering data from the field,
               controlling, editing and aggregating local GATS data prior to sending it to the central office in Ankara.
               The pilot test targeted to reach at least 24 individuals aged 15 years or older in each TurkStat regional offices
               (26 regions). Given that GATS aim to get estimates for rural and urban settings and also specific rates for
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               males and females, separately, and given the fact that age of the respondent may affect the understandability,
               flow and duration of the interview, each interviewer was requested to reach one member from each subgroup
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               of gender (male, female), current smoking status (smoking/nonsmoking), and age groups (15-39 ages, 40-64
               ages and 65 and older ages) in both rural and urban setting, randomly chosen for that province and subclass.
               The sampling department selected random samples for each province and gave addresses in rural and urban
               settings and wanted to investigate the completion rates for selected addresses.


               After trainings, 26 regional offices of TurkStat implemented the pilot study at the first week of September
               2008. During the pilot study, both handhelds and paper questionnaires were used in 10 provinces, whereas,
               only handhelds were used in 16 provinces. Data collection was conducted by mostly university-graduate
               interviewers and supervisors and a total of 746 interviews were completed in rural and urban areas.

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               The GATS Turkey questionnaire consists of eight sections: background characteristics, tobacco smoking,
               smokeless tobacco, cessation, secondhand smoke, economics, media, and knowledge, attitudes and
               perceptions. Questions adapted in each section are based on a standard core and optional set of questions
               provided and approved by a questionnaire expert review committee and country-specific questions include
               waterpipe/shisha.
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               Sampling Design
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               GATS sample design was prepared appropriately by GATS Sample Design Manual and then revised in
               accordance with the committee's questions. All households in Turkey borders were covered. The institutional
               population living in dormitories, hospitals, jails, rest homes and soldiers is excluded from the study.
               Sample size of the survey is calculated to do estimations on the base of total of Turkey. The frame used in
               sampling studies of survey is the National Address Database (September 2008) which is the base of 2007
               Address Based Population Registry System. By the use of 2006 Turkish Time Use Survey results, the total
               sample size calculated as 11200 households. So, 5600 respondents per each region (urban/rural) and in each
               region 2800 males and 2800 females were selected.



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               The sample design of the survey is 3 staged stratified systematic cluster sampling method.
               i)     In all urban areas the frame was divided into clusters of approximately 300 households each. These
                      were selected with equal probability using systematic sampling. The same procedure was applied to
                      rural areas where localities have been divided into clusters.
               ii)    In the second stage, sample households were chosen from the selected clusters (blocks) using
                      systematic selection method. In this stage, 28 households were chosen systematically in each cluster
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                      and then households were divided into 2 equal size groups as ‘female households’ and ‘male
                      households’ randomly. Thus, in each cluster there were 14 male households and 14 female households.
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               iii)   In the last stage, one individual was selected randomly within the selected each household related with
                      male or female household. This procedure was done by IPAQs.


               Settlements with population 20.000 and below classified as rural, and with population 20.001 and over
               classified as urban. The total sample size is 11 200 households. 400 Clusters (blocks) constitute the sample.
               200 of these selected clusters (blocks) were chosen from urban areas and other 200 clusters (blocks) were
               chosen from rural areas. Since non-response was also taken into account, substitution was not used in survey.




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               Study in Regional Offices Main Field
               The field study was carried on a minimum of 10 days, maximum of 28 days, according to the workload of
               region. TurkStat central office requested to get regularly a report containing how the field work going on in
               Regional Office each Monday until the field work was completed. This report guided TurkStat to check and
               solve any problems before completing field study. E-mail group was constituted to share experiences and
               solve the field problems instantly. The people responsible for specific areas such as IPAQs, programming,
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               sampling, technical issues and questionnaires answered the questions asking by supervisors and interviewers.
               The field study was completed by December 5th, 2008.
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               The preliminary results of GATS were announced by press release on April 30th, 2009. Final results will be
               published on July, 2009. GATS Primary Indicator Guidelines will be used for the publication. Micro data of
               GATS will be available for researchers.




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               Response Rate
                                                Table 1: Reasons of non-response, 2008.
                                                                             Household      Individual
                               Total                                        11 200 100,0    9 322 100,0
                               Completed                                     9 322 83,2     9 030 96,9
                               Incomplete                                      175    1,6       5    0,1
                               No screening respondent                         602    5,4
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                               Refused                                          22    0,2     12     0,1
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                               Unoccupied                                      536    4,8            0,0
                               Other (incapacitated, wrong address, ect.)      543    4,8    275     3,0
                     The total of 9322 sample households was interviewed and non-response forms were filled due to
               various reasons (no screening respondent, unoccupied, etc.) for 1878 households. 9030 individuals were
               interviewed (Table 1).


               3. Main Results of GATS
               According to the results of 2008 GATS, 31,3% of respondents aged 15 years and older smoke daily or less
               than daily. This ratio is 47,9 % for male and 15,2 % for female. 52,8 % reported that they have never smoked
               in their lives. 30 % of male and 74,8 % of female reported that they have never smoked (Table 2).


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                                                           Table 2: Tobacco use in Turkey, 2008.
                                                                           Turkey                    Urban                     Rural
                                                                   Total    Male    Female   Total    Male    Female   Total    Male    Female
               Current tobacco smoker                               31,3     47,9     15,2    33,0     47,9     18,7    27,2     48,0      7,2
               Daily tobacco smoker                                 27,4     43,8     11,6    29,0     44,0     14,5    23,9     43,6      5,0
               Occasional tobacco smoker, formerly daily             1,8      2,1      1,5     1,9      2,1      1,6     1,6      2,2      1,0
               Occasional tobacco smoker, never daily                2,1      2,0      2,1     2,1      1,8      2,6     1,7      2,2      1,2
               Non-smoker of tobacco                                68,7     52,1     84,8    67,0     52,1     81,3    72,8     52,0     92,8
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               Former (ex-) daily tobacco smoker                    10,5     17,2      4,1    10,5     16,4      4,8    10,5     18,9      2,5
               Former (ex-) occasional tobacco smoker                5,4      4,9      5,9     5,6      4,8      6,2     5,1      5,1      5,1
               Never smoker of tobacco                              52,8     30,0     74,8    50,9     30,9     70,3    57,2     27,9     85,2
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               Toplam                                              100,0    100,0    100,0   100,0    100,0    100,0   100,0    100,0    100,0



                        In urban areas 33 % of persons smoke daily or less than daily, in rural areas this figure is 27,2 %.
               The ratio of never smoked is 51 % for urban areas and 57,1 % for rural areas.




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                                         80,0
                                         70,0
                                         60,0
                                         50,0

                                         40,0
                                         30,0

                                         20,0
                                         10,0
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                                           0,0
                                                      Daily     Less than daily   Not at all   Never used
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                                        Total         27,4            3,9           15,9          52,8
                                        Male          43,8            4,1           22,1          30,0
                                        Female        11,6            3,6           10,0          74,8



                                                 Graph 1: Percentage of persons smoking by sex.
                       When tobacco users are examined by age group, mostly persons in 25-44 age group reported to
               smoke daily or less than daily. It is 40,3 % in 25-34 and 39,6% in 35-44. When looked by sex for 25-34 age
               group male this ratio is 58 %, and for female it is 22,4 %. In 35-44 age group the figure is 58,4 % for male
               and 20,5 % for female.




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                                            45,0

                                            40,0

                                            35,0

                                            30,0

                                            25,0

                                            20,0

                                            15,0

                                            10,0
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                                             5,0

                                             0,0
                                                   Total   15-24   25-34   35-44   45-54   55-64   65+
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                                          Turkey   31,3    25,4    40,3    39,6    32,3    24,7    10,3
                                          Urban    33,0    25,6    42,3    40,3    34,0    26,6    9,8
                                          Rural    27,2    24,8    34,4    37,7    28,3    21,3    10,9




                                    Graph 2: Percentage of persons smoking daily or less than daily.


                       Among users of tobacco 94,5% are aware of health warnings on cigarette packages, among who
               don’t use tobacco this ratio is 74,6 %. The ratio of awareness in 15-24 age group individuals is quite close
               for users and not users.




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               The ratio is 93,9 % for users and 87 % for not users. On the other hand, awareness of 65 years and older
               individuals who use tobacco is 86,4 % and for those who don’t use the ratio is 39,5 %.


               When we look at the approach of 15 years and older persons who currently smoke tobacco, 53 % of them
               reported thinking about quitting smoking tobacco. 27,8 % of them reported thinking about quitting in the 12
               months following the interview and 25,2 % of them reported thinking about quitting, but not in the 12
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               months following the interview. 42,4 % of them reported that they are not interested in quitting.
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               4. Conclusions
               Turkey has made substantial progress in tobacco control during the last 10-12 years. The first Anti-Tobacco
               Law came into force in 1996, which was substantially amended in 2008. In 2008, Law No. 4207 was
               amended in order to turn all indoor public places, workplaces, educational institutions and premises, public
               transportation (including taxis) into 100 % smoke-free environments, as well as introducing a near complete
               ban in sports and other events venues, with a first phase for general implementation in all places apart from
               hospitality workplaces, that started on 19 May 2008 and a second phase that will extend the smoking ban to
               all hospitality workplaces, starting on 19 July 2009.



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               2008 GATS was conducted 5 months later after the new regulation. Despite a short period of time to pass out
               of the positive effects described in the GATS is seen as research. According to Turkish Family Structure
               Survey, 33,4% of persons aged 18 years and older smoke in 2006. In the results of 2008 GATS, 32,3 % of
               persons for same age group. This ratio is 50,6 % for male and 16,6 % for male in 2006. In 2008 this ratio
               decreased 49,7 % for male and 15,9 % for female in 2008. Research on tobacco use in Turkey back to certain
               periods, this development will allow a much better.
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               REFERENCES
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               [1]   TurkStat, Global Adult Tobacco Survey, 2008, Press Release, 30 April 2009.
               [2]   GATS, Country Proposal Development Guidelines, Edited on 17 July 2008.
               [3]   Global Tobacco Surveillance System (GTSS), Global Adult Tobacco Survey (GATS): Sample Design
                     Manual. 2008.
               [4]   Global Tobacco Surveillance System (GTSS), Global Adult Tobacco Survey (GATS): Core
                     Questionnaire with Optional Questions. 2008.
               [5]   Global Tobacco Surveillance System (GTSS), Global Adult Tobacco Survey (GATS): Data Release
                     Policy, CDC, January 2009.
               [6]   WHO, MPOWER: A Policy Package Reverse the Tobacco Epidemic, Switzerland.
               [7]   TurkStat, Turkish Family Structure Survey, 2006.

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